HomeMy WebLinkAboutWAI2025-00072 - WAI Health Waiver - 9/10/2025 ;. , ,''ti'\ 415 N. 6'STREET,SHELTON WA 98584
MASON COUNTY SHELTON:360-427-9670,ext 400
1 l' COMMUNITY SERVICES BELFAIR: 360-275-4467,ext.400
\; --''i - ELMA: 360-482-5269,ext.400
, Building.Planning,Environmental Health,Community Health
: / FAX:360-427-7798
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oolication for Waiver or Appeal ��
Amount Paid: " >nta0 Receipt Number: a��5 "O LJ jtZg S c't�� \
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Instructions: 1
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1. Complete Parts 1 and 2. No determination can be made until these parts are fully cometatett
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 Information
Name of Applicant Li Xia Ye Telephone 425-653-2485
Mailing Address 3990 129th PI SE, Apt C202
City Bellevue, State WA Zip 98006
Parcel No. 3 2 0 2 1 -- 5 3 -- 0 1 0 4 4
Site Address 121 E Shoreline Ln, Shelton, WA 98584
Subdivision Name and Lot Shorecrest Add Replat, BIk:1 , Lot: 44
PART 2: Nature of Waiver/Appeal
❑ Onsite: Class A Waiver 0 Food Sanitation Requirements
❑ Onsite: Class B Waiver 0 Group B Water System Regulations
❑ Onsite: Class C Waiver 0 Water Adequacy Requirements
/ Onsite: Location, WAC246-272A-0210 0 Building Permit: EH Review Policies
❑ Onsite: Holding Tank, WAC246-272A- 0 Appeal:Enforcement Timelines
0240 0 Appeal: Departmental Determinations
❑ Onsite: Contractor Certification 0 Other
Requirements
Description of Waiver/Appeal (include justification. additional material may be attached.):
Reduce setback from drainfield primary and reserve to north and east property lines
from 5 ft down to 2 ft minimum. Drainfield is donw-slope of property lines so septic effluent will drain
away from property line.
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Applicant Signature: c ..� Date: l - ( 0 -��
V'rw� bE C-- c,- � e , r - Revised 81 13/201 s
This form may be scanned and availabl for public view on the Mason County Web site.
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PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver (if applicable) , , ,
Appeal Waiver None required Class A Class B Class C LOB J
2. Identification of Specific Code/ Standard/ Determination (include date of determination or
1
latest Code/ Standard revision): vv -i(-1.L,-7,-77 A-0 -L Q
3. Nature of Appeal: 7-- 1 (k_L
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4. Hearing Official:
❑ Board of Health 0 Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board J. Environmental Health Manage✓
5. Mitigating Factors: ^I L,t o f
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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: bli\-)211 (CNINN Date: q,(t (0(71c
PART 4: Determination of the Hearing Official
in,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:
❑ 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:
Health Official Signature: Date: IA
R L\i sed 8/13/2018
This form may be scanned and available for public view on the Mason County Web site.
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