HomeMy WebLinkAboutWAI2025-00078 WAIVER FOR APEAL - WAI Health Waiver - 10/10/2025 I0
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415 N.6th STREET,SHELTON WA 98584
V SHELTON:360-427-9670,ext 400
MASON COUNTY BELFAIR:360 275 4467,ext.400
ow COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health
Application for Waiver or Appeal �7'-�, Q,
Amount Paid: 20 (7 Receipt Number: &5� 0 C- `-' ) (J
WAI '`.O00--7
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
VCC\VA-\\-- () ��') Cs-OName of Applicantnt���e� \ TelephonE /*
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Mailing Address c�r \ \�tp Y\----- •
City )\\-'('r--) State VI F\ Zip C A V
c� `? - 0 C)
Parcel No. ot,. � \ � , � - �� \
\`fie �c� ���-, \—\\\�C) \`�' 57\-\,\,Th 4-\ � y Site Address }
Subdivision Name and Lot P_\,--;\-\ \___Ci. T .\\ . \ ;C"-)
PART 2: Nature of Waiver/Appeal
❑ Onsite: Class A Waiver 0 Food Sanitation Requirements
❑ Onsite: Class B Waiver 0 Group B Water System Regulations
❑ Onsite: Class C Waiver 0 Water Adequacy Requirements
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
❑ Onsite: Contractor Certification 0 Other
Requirements
Description of Waiver/A.peal •nclu•e justification, additional material ma be attache•.):
va . s .Wiiti a alle tlea ► _rim:,
-,_2--' " •
APPlicant Signature: \ _ >�� IA
ate: \D "\b---`
Revised 9/29/205
This form may be scanned and available for public view on the Mason County Web site.
Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver (if applicable)
Appeal7Waiver u None required n Class A n Class B ri Class CX Local
2. Identification of Specific Code/ Standard/ Determination (include date of determination or
latest Code/ Standard revision): VII*Z12--( 6-Z7Z.44- -02A 0
3. Nature of Appeal: y...‘24k
u L+ - s
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 il Factors lA nLs U � � D � a •
U1� il,(1- - � J
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:
TV ��n Date: I I 1 ZS
PART 4: Determination of the Hearing Official
PS- 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:
0 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: l 7l 74/
Revised 9/29/2025
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
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