HomeMy WebLinkAboutWAI2025-00075 - WAI Health Waiver - 9/17/2025 ,� 415 N.6th STREET,SHELTON WA 98584
1li MASON COUNTY SHELTON:360-427-9670,ext 400
I,,. It' l COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400
ELMA:360-482-5269,ext.400
\\ Building.Planning,Environmental Health Community Health FAX:360-427-7798
Application for Waiver or Appeal 0 ECLI
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Amount Paid: . Receipt Number: SEP
_� ; 17 2025
WAI aaa5 - C)o o 15 ';b
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Instructions: -.___`___
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 Information
Name of Applicant Empire Home Construction Telephone (360)751-8062
Mailing Address P.O. Box 241
City Kelso State WA Zip 98626
Parcel No. 3 2 2 3 2 -- 5 2 -- 0 9 0 1 5
Site Address 191 E Alderney St, Union, WA 98592
UNION-GRAYS HARBOR&UCRR ADD BLK:9 LOTS 15-18 S 46/89 DPC#25-26 AF#2226691
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
il ❑ Onsite: Class A Waiver 0 Food Sanitation Requirements
0 Onsite: Class B Waiver 0 Group B Water System Regulations
0 Onsite: Class C Waiver 0 Water Adequacy Requirements
3" 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
0 Onsite: Contractor Certification 0 Other
Requirements
Description of Waiver/Appeal (include justification, additional material may be attached.):
Reduce setback from foundation to septic tanks from 5 feet to a minimum of 2 feet
and drainfield from 10 feet to a minimum of 2 feet. Mitigation is that septic tanks and drainfield are both downslope
of house/foundation. Effluent will drain away from house.
Applicant Signature: \ Date: - I ZS
�Sti c'-- _ cD-Q,�'-gV,4I 49. FC.-(-u-- Revised 8/13/2018
This form may be scanned and available for public view on the Mason County Web site.
Page I of 2
PART 3: Public Health Evaluation (Staff Use Only) 1°C °L,\
1. Type of Determination Required: Type of Onsite Waiver (if applicable)
Li Appeal c Waiver None required Class A c Class B c Class C
2. Identification of Specific Code/ Standard/ Determination (include date of determination or
latest Code/ Standard revision):
3. Nature of Appeal: C-f
6OL)ivd 00- d 9 o/cm.
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
0 Certified Contractor Review Board ❑ Environmental Health Manage
5. Mitigating Factors: ( 40 69c.)v
•r ,f /
6. I have received this waiver/appeal request. It is complete and mitigation required by the
state and local polio has been submitted.
•
Staff Signature: e66 w/(/y(, Date: JO���~�J
PART 4: Determin ion of the Hearing Official
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: Cv/�
R Wised 8/13/2018
This form may be scanned and available for public view on the Mason County Web site.
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