HomeMy WebLinkAboutWAI2026-00067 - WAI Health Waiver - 8/13/2026 415 N.6 STREET,SHEST0N WA 9S534
MASON COUNTY fl °°
`400
Public Health & Human Services
Application for Waiver or Appeal
Amount Paid. S e C) Receipt Number. ��" n 34
35
WAI - OILi1
Please 1 all approved Onsite Waivers have the same expiration date as their OSS Permits.
Instructions:
1. Complete Parts I and 2. No determination can be made until these parts are fully completed.
2. Fees maybe 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
John Killbourne Telephone (253) 448-9036
Mailing Address 611 Yakima Ave S
City Tacoma, State WA zip 98405
Parcel No. 3 2 1 0 4 _ 5 0 __ 0 0 0 4 5
Site Address 71 E Country Club Dr E, Union, WA 98592
Subdivision Name and Lot Alderbrook Golf & Country Club, Lots 5 & 45
PART 2: Nature of Waiver/Appeal
❑ Onsite Class A Waiver ❑ Food Sanitation Requirements
❑ Onsite. Class B Waiver ❑ Group B Water System Regulations
❑ Onsite Class C Waiver ❑ Water Adequacy Requirements
I] Onsite. Location. WAC246-272A-0210 O Building Permit: EH Review Policies
❑ Onsite: Holding Tank WAC246-272A- ❑ Appeal: Enforcement Timelines
0240 ❑ Appeal Departmental Determinations
❑ Ons'ite. Contractor Certification ❑ Other
Requirements
Description of Waiver/Appeal ('include justification, additional material may be attached.).
Reduce setback from foundation to drainfield from 10 ft down to 2 ft minimum. The
adjacent drainfield area is down-slope of foundation. Setback reduction needed to
install a secondary drainfield as original was installed improperly and must be
backfilled/abandoned.
Applicant Signature: Date: b -3` tL
03'03/2046
This form may be sc�n edva d vaila'ble for pu tic vi Non the Mason County Web site.site. r
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver (if applicable)
❑Appeal [J Waiver ❑ Class A ❑Class B ❑Class C L1/Local
T State Waiver Criteria
Number of Bedrooms: J Nitrogen Treatment: ❑Yes X No
Soil Type: 3 Minimum Lot Size: 1&� 000 sq.ft.
Water Source: 7t
®Public ❑Private This Lot Size: `f ?59' sq.ft.
Is This Lot Eligible for State Waivers: MYes ❑ No ❑ N/A
Hear g Official:
F Environmental Health Manager ❑ Public Health Director ❑ Other:
2. Identification of Specific Code' #�ttandard/ Determinatioqn (include date of determination or latest
Code/ Standard revision): IV 0O ZfO
3. Nature of Appeal:
Reduce tke, nn i' m Iw? '?0nfol jp. çrg14 bot r
wtn + i orry (OFf fo hod PS {,
5. Mitigating Factors:
TAP, '& vndafebn i`5 ad down -omlt&ni -
6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state
and local policy as been submitted.
Staff Signature. 7/hy ___ 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: WI
Revised 03/03/2026
This form may be scanned and available for public view on the Mason County Web site. Page 2 ore