HomeMy WebLinkAboutWAI2025-00091 - WAI Health Waiver - 12/18/2025 415 N.6th STREET,SHELTON WA 98584
• ? '..P q SHELTON:360-427-9670,ext 400
ieti4 MASON COUNTY BELFAIR:360-275.4467,ext.400
, COMMUNITY SERVICES
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%, Building F'lannrna.Fnvac nmr-nlal Health.Community Health
Application for Waiver or Appeal L;
Amount Paid: 4 D.v� Receipt Number. -77 G` OFC ��
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WAI �L�q I 425
Please note,all approved Onsite Waivers have the same expiration date as their OSS Perm
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 2-)
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Name of Applicant �/` P
Mailing Add/ress 6 b
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City .S��VZ State !GA Zip l d /()=�
Parcel No. 3 / ! L 7 -- - C) -- L( ) `'' '/
Site Address /3/ `-tl• FEv,m L4/. , . 'V)$( / Z / /lb /,,rJ 1.
Subdivision Name and Lot /)2)1,M /it4I 14/1: vAr)r
PART 2: Nature of Waiver/Appeal
❑ Onsite: Class A Waiver 0 Food Sanitation Requirements
❑ Onsite: Class B Waiver 0 Group B Water System Regulations
O Onsite: Class C Waiver 0 Water Adequacy Requirements
❑ Onsite: Location,WAC246-272A-0210 x Building Permit: EH Review Policies
O Onsite: Holding Tank,WAC246-272A- 0 Appeal: Enforcement Timelines
0240 0 Appeal: Departmental Determinations
❑ Onsite: Contractor Certification 0 Other
Requirements
Description of Waiver/Appeal(include justification, additional material may be attached.):
.i F)4c; ii Aer%?G'1J tfo/)2R 72' ,t3f� 7cr , ?J sF i7-6
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Applicant Signature:,) �['C� /7 >/).4V)46 Date:
-/ZY---: t2 5
Revised 9/29/2025
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)
Appeal 7 Naiver None required Class A Class B Class C Local
2. Identification of Specific Code/ Standard/ Determination (include date of determination or
latest Code/Standard revision):
3. Nature of Appeal: Ow,
G 1A1r fief d /i--Sty
4. Hearing Official:
❑ Board of Health 0 Health Officer
0 Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board Environmental Health Manager
5. Mitigating Factors: 4.0 ot,`:1Gr\ .I 7/1 ,` /act-A hawk
, '• 1,ii�r%IN ' • I 1 / : LAPA ' mil'
6. I have received this waiver/appeal request. It is complete and mitigation required by the
state and local policy has been submitted.
iF1 Staff Signature: ZDate: ( Z\
"l PART 4: Determination of the Hearing Official
is.. 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'V6/
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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