HomeMy WebLinkAboutWAI2025-00053 - WAI Health Waiver - 7/15/2025 MASON COUNTY
COMMUNITY SERVICES
Building,Planning,Environmental Health,Conimunity Health
415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 ❖ Belfair: (360) 275-4467 ext 400 4. Elma: (360) 482-5269 ext 400
FAX (380) 427-7787
Application for Waiver/Appeal W
Amount Paid: ft 2-o IECE[I o
'Receipt Number: Q002 --o 11 JUL 1 2025 .J
Instructions t{\ 6)- 6- 00(")5'3
By
1, Complete Parts 1 and 2. No determination can be made until these parts are fully comp e ed.
2. Fees may be billed for waivers and appeals, based on the Environmental Health Fee Schedule.
3. Submit completed application with attachments to Mason County Public Health for review.
PART 1. Applicant/Parcel Identification
Name of Applicant Pandora Hope Telephone (360) 536-5098
Mailing Address of Applicant 4455 NW Shelly Drive
City Silverdale State WA Zip 98383
12-digit Tax Parcel No. 3 2 1 2 7 5 3 __ 0 0 2 0 7
Site Address 422 E Olde Lyme Rd
•
Subdivision Name and Lot Plat of Lake limerick#4, Lot 207
PART 2: Nature of Waiver/Appeal
O Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
❑ Separation Cl Food Sanitation Requirements
❑ Building Permit Review Policies 0 Group B Water System Regulations
Location, WAC 246-272A-0210 El Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
• XI Mason County Onsite Standards ❑ Departmental Determinations
❑ Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
Request horizontal separation setback reduction for existing pressure bed drainfield
to NE corner of proposed SFR from 1U feet down to b feet. Treatment level on existing
drainfield to be increased from I L t to I L t3. Adding pump control panel to allow timed
dosing to araintiela
Applicant Signature: Date: 07/15/2025
J:\F,H Fonns\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver (if applicable)
Li Appeal *Waiver n None required r= Class A :7 Class B L. Class C L 7._
2. Identification of Specific Code/Standard/Determination (include date of determination or latest Code/
Standard revision)
7i4(����Zy -�( (�
3. Nature of Ap eal: rr
t ctPr ry TD (=r
4. Hearing Official:
❑ Board of Health 0 Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board ,4 Environmental Health Manager
5. Mitigating Factors:
- (4 o I'\c i-Yi ; S bolo- gYcd.Q ; 5rh yhe l S �r?tt ,c13
QtLv . - 0msTSSr fYY 1meCY( 0/
?In"A1--S S I Ict' v
7 f re-Are-A-e r `,01,e/to(TGn-f- -ccuJ-o,)`-i .
6. I have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted.
Staff Signature: Date: 1112 IL(
PART 4: Determination of the Hearing Official
a The hearing official has determined that approval of this request will not adversely affect public health and
is hereby granted. This decision is based on the following findings and conditions:
0 The hearing official has determined that approval of this request could potentially adversely effect public
health and is hereby denied. This decision is based on the following findings and conditions:
Hearing Official Signature: Date:
7/Zf
•
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of 2