HomeMy WebLinkAboutWAI2025-00055 - WAI Health Waiver - 9/16/2025 c�z MASON COUNTY
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415 N 6`h Street, Bldg 8, Shelton WA 98584,
Shelton: (360L427-96Zuext-430 •:• Belfair: (360) 275-4467 ext 400 ❖ Elma: (360)482-5269 ext 400
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' Application for Waiver/Appeal �/� 0� 5
E SEP 1 6 Z�ZS Amount Paid: * vAT a0 5-
Receipt Number:
Inst gOition
1. Complete Parts 1 and 2. No determination can be made until these parts are fully completed.
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 SAM HAYES Telephone
Mailing Address of Applicant 3689 SAGE BRUSH LN NW
City BREMERTON State WA Zip 98312
12-digit Tax Parcel No. 3 2 1 2 4 - __ 5 2 _= 0 0 0 2 5
Site Address 311 EMERALD LAKE DRIVE WEST, SHELTON
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
❑ Separation 0 Food Sanitation Requirements
O Building Permit Review Policies 0 Group B Water System Regulations
if Location, WAC 246-272A-0210 0 Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
O Mason County Onsite Standards 0 Departmental Determinations
❑ Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
REDUCE SETBACK FROM DRAINFIELD TO LAKE FROM 100FT DOWN TO 75FT
XO-2 SYSTEM MEETS TL-A W/OUT DISINFECTION AND HAS 24"OF V/S FOR"ENHANCED"TREATMENT
BEYOND THAT REQUIRED IN TABLE VI.
Applicant Signature:Q,T, `k-PnO491 Date: CI 1 I5/
J:\EH Forms\Waiver-Appeal Mason Count}'Local Revised 1/20/2017
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PART 3: Public Health Evaluation (Staff Use Only) ¶ 0
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
Appeal Waiver None required Class A Class B Class C
2. Identification of Specific Code/ Standard/ Determination (include date of determination or latest Code/
Standard revision)
3. Nature of Appeal: 7 5 -1--0 5,(I�c.c C.1/r/l (-
4. Hearing Official:
O Board of Health 0 Health Officer
O Pollution Control hearing Board 0 Public Health Director
O Certified Contractor Review Board Environmental Health Manager
5. Mitigating Factors: _ /1./ Geot
6. I have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been ubmitted.
Staff Signature: (1JLjL'\9 r"- Date:
PART 4: Determina ion of the Hearing Official
X-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: `f
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
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