HomeMy WebLinkAboutWAI2025-00084 - WAI Health Waiver - 11/4/2025 p soN co,m, aoa. 5sq),
Public -49 Health
Always working for a safer i healthier Mason County
415 N 6th Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 •:• Belfair:(360)275-4467 ext 400 s• Elma:(360)482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal � �����
Amount Paid: c 2c3` -' c'-' NOV 0 4 2025 c",
Receipt Numbet5 "
BY:
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 Identification
Name of Applicant
haven Green Telephone 706-4?3-9650
Mailing Address of Applicant 8312 Sierra Dr; Edmonds,WA 98026
City Edmonds State WA Zip 98026
12-digit Tax Parcel No. 2 2 n 1g -- S 0 -- o
428
Site Address .364 E Timberlake Rd E; Shelton 98584
Subdivision Name and Lot Timberlake #1 Lot 100
PART 2: Nature of Waiver/Appeal
❑ Class B Reduction in Vertical Separation 0 Food Sanitation Requirements
0 Building Permit Review Policies 0 Group B Water System Regulations
17 Location, WAC 246-272A-0210 0 Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
❑ Mason County Onsite Standards 0 Departmental Determinations
❑ Contractor Certification Requirements ❑ Other
(Installer,Pumper,O&M Specialists)
Description of Waiver/Appeal (include justification,additional material may be attached.):
5'setback of infiltrative surface from foundation
Drain field is downslope from home on site and home is a manufactured home
Applicant Signature: Date:
10/16/25
1:\EH Forms\Waiver-Appeal Mason County Local Revised 12/1/15
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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 o None required Class A I Class B Class C (�DCA'L�
2. Identification of Specific Code/Standard/Determination (include date of determination or
latest Code/Standard revision) ,)SC/771,(E,,L1'ZA--07A.-CD
3. Nature of Appeal:
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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 Environmental Health Manager
5. Mitigating Factors:
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6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state
and local policy has been submitted.
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Staff Signature: �wN Date: < i fl-7_,,,s----
PART 4: Determination of the Hearing Official
L 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:
Hearing Official Signature: Date: 1///
J:\EH Forms\Waiver-Appeal Mason County Local Revised 12/1/15
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