HomeMy WebLinkAboutWAI2026-00071 - WAI Health Waiver - 8/20/2026 415 N.6"STREET,SHELTON WA 98584
ASON COUNTY SBEF°R 360275446 xtt400
Health & Human Services
�11C1 ;' 101.6
Application for Waiver or Appeal
Receipt Number: - (f
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WAI ��Xr 9 - D0O7l
Please ote all approved Onsite Waivers have the a 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 Warren Wilcox Telephone 8016553900
Mailing Address 1632 E Benson Lake Dr
city Grapeview State WA Zip 98546
Parcel No. 2 2 1 0 3 -- 5 1 _ 0 0 0 2 1
Site Address 1632 E Benson Lake Dr, Grapeview
Subdivision Name and Lot Benson Lake 2 Tr 21
PART 2: Nature of Waiver/Appeal
0 Onsite. Class A Waiver ❑ Food Sanitation Requirements
❑ Onsite: Class B Waiver ❑ Group B Water System Regulations
❑ 9nsite: Class C Waiver ❑ Water Adequacy Requirements
Onsite Location, WAC246-272A-0210 ❑ Building Permit'. EH Review Policies
❑ Onsite: Holding Tank,WAC246-272A- ❑ Appeal:Enforcement Timelines
0240 ❑ Appeal: Departmental Determinations
❑ Onsite: Contractor Certification 0 Other
Requirements
Description of Waiver/Appeal (include justification, additional material may be attached.)'.
reduction in setback from drainfield to well (75ft), using increased treatment level (TL
A)
Applicant Signature:
Date: 8/14/26
Revised n3'oarzoxe
This form may be scanned and available for public view on the Mason County Web site.
''age I or1
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver (it applicable)
❑Appeal Waiver ❑Class A ❑Class B ❑Class C Local
State Waiver Criteria
Number of Bedrooms: Nitrogen Treatment: ❑Yes O 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
Hearing Official:
Environmental Health Manager ❑ Public Health Director ❑ Other:
2. Identification of Specific Code/ Standard)/ Determination (include date of determination or latest
Code/ Standard revision): y4y'Lttlp.277 4-07.10
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 has been submitted.
Staff Signature: Y` M'f't" I/� Date: ef?-012b
PART 4: Determination of the Hearing Official
E7 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: /12 _ _ "% - t Date.
Hevkcd 03/( 2026
This form may be scanned and available for public view on the Mason County Web site. Page