HomeMy WebLinkAboutWAI2026-00049-WAI - WAI Health Waiver - 7/1/2026 415 N. 6`h STREET,SHELTON WA 98584
MASON COUNTY SBEL AON.3674!
IR: 360-2
Public Health & Human Services (' � j
026
By
Application for Waiver or Appeal
Amount Paid: l�J Receipt Number: )— O a (h:15
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Please note, all approved Onsite Waivers have the same expiration date as their OSS Permits.
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 LOW TIDE LLC Telephone
Mailing Address PO OX 6858
City TACOMA State WA zip 98417
Parcel No. 2 2 1 0 3 __ 5 0 0 0 0 2 6
Site Address 140 E BENSON LK DR
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
El Onsite: Class A Waiver El Food Sanitation Requirements
❑ Onsite: Class B Waiver El Group B Water System Regulations
❑ Onsite: Class C Waiver El Water Adequacy Requirements
El Onsite. Location. WAC246-272A-0210 El Building Permit: EH Review Policies
❑ Onsite: Holding Tank, WAC246-272A- El Appeal: Enforcement Timelines
0240 El Appeal: Departmental Determinations
El Onsite: Contractor Certification El Other
Requirements
Description of Waiver/Appeal (include justification, additional material may be attached.):
REDUCE SETBACK FROM TANKS TO FOUNDATION FROM 5FT DOWN TO 2FT
FOUNDATION WILL BE UPGRADIENT. REDUCTION NEEDED TO MAINTAIN
LAKE & WELLS SETBACK
Applicant Signature: a J Date: &
Revised 03/03/2026
This form may be scanned and available for public view on the Mason County Web site.
Page 1 of 2
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PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
❑Appeal O Waiver ❑ Class A ❑Class B ❑Class C � Local
State Waiver Criteria
Number of Bedrooms: Nitrogen Treatment: ❑Yes El No
Soil Type: Minimum Lot Size: sq.ft.
Water Source:❑Public ❑Private This Lot Size: sq.ft.
Is This Lot Eligible for State Waivers: ❑Yes ❑ No N/A
Hearing Official:
0 Environmental Health Manager ❑ Public Health Director ❑ Other:
2. Identification of Specific Code/ Standard/ Determination (include date of determination or latest
Code/ Standard revision): k/R(-Z46.?f Zoo-Z l0 (3)
3. Nature of Appeal:
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5. Mitigating Factors:
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6. I have received this waiver/appeal request. It is complete and mitigation required by the state
and local policy been submitted. z/
Staff Signature: Date:
PART 4: Determination 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: / 1 / ? L17
Revised 03/03/2026
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of'2