HomeMy WebLinkAboutWAI2026-00008 - WAI Health Waiver - 1/21/2026 r
415 N. 6th STREET,SHELTON WA 98584
SHELTON:360-427-9670,ext 400
MASON COUNTY BELFAIR:360-275-4467 ext.400
•i I COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health j, t � `�1
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Application for Waiver or Appeal >8j," 4. / Z026 e
Amount Paid: It 310 Receipt Number: oaO,)-.(p- 00 3'-
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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 '%AA L-VA,s-t-S*- Telephone "3 Ca 0 `Z 53- i-1 Uo
Mailing Address T..o, '34 l(121-
City O Ls( State (AJ A Zip 0 e 5`O1
Parcel No. S "Z 0 O d -- g O -- 6 v 0 0 5
Site Address L2 ,u,cicZ O o% L. 4C-_--.L.—Co
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Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
It Onsite: Class A Waiver O Food Sanitation Requirements
❑ Onsite: Class B Waiver 0 Group B Water System Regulations
❑ Onsite: Class C Waiver 0 Water Adequacy Requirements
04 Onsite: Location,WAC246-272A-0210 0 Building Permit: EH Review Policies
❑ Onsite: Holding Tank,WAC246-272A- O Appeal:Enforcement Timelines
0240 0 Appeal:Departmental Determinations
❑ Onsite: Contractor Certification O Other
Requirements
Description of Waiver/Appeal (include justification, additional material may be attached.):
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Applicant Signature: Date:
Revised 9/29/2025
This form may be scanned and available for public view on the Mason County Web site.
Page 1 of 2
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On-Site Sewage Systems (Chapter 246-272A WAC) Washington Stat.o,p,nm,ntof
Request for Waiver from State Regulations '� H E A LT H
Section I. I (Completed by applicant)
Name: (1) • Local Health Jurisdiction Received (2)
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Address:
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Telephone:
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Signature:
Property Ide ification: (3) S1-006—
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Section II. I (Completed by applicant)
WAC Number:(4) WAC Requirement: (5) Waiver Sought: (6)
246-272A- O1.-T1):: au 1i-bl 5 NLQ KATSSVRAC
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Justification(Proposed mitigation measures): (7)
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Section III. I (Completed by local health officer)
Review Criteria: (8) Additional Mitigation Measures: (9)
Comments/Conditions: (10)
Type of Waiver: (11)rClass A []Class B []Class C- Request DOH review before granting? Yes n Non
Neighbor Notification: (12) Required?Yes[]No n If needed,are agreements, easements,etc.filed? Yes [] Non
Section IV. I (Completed by health officer)
This Request for Waiver from State Regulations has been reviewed according to the provisions of Chapter 246-272A WAC On-Site
Sewage Systems.The review criteria applied, and the mitigation measures proposed and/or required, have been evaluated for
their ability to provide public health protection at least equal to that provided by this chapter WAC.
[]Denied ), I Approved/Granted -Sub' ct all comments,conditions and requirements noted in Sections II and III.
Local Health Officer(13)_ Date: l,/Z f/Z
DOH 337-175 February 2024 1
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PART 3: Public Health Evaluation (Staff Use Only) 15 20i 0Vb 51'x"
1. Type of Determination Required: Type of Onsite Waiver(if applicable) .eA T o eb'- -"
❑ Appeal Waiver ❑ None required Class A ❑ Class B ❑ Class C S '6 •
2. Identification of Specific Code/ Standard/Determination(include date of determination or
latest Code/ Standard revision) V'LZ9,(,),L1 Lh—o7. c7
3. Nature of Appeal:
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4. Hearing Official:
❑ Board of Health O Health Officer
❑ Pollution Control hearing Board �7 Public Health Director
❑ Certified Contractor Review Board j�- Environmental Health Manager
5. Mitigating Factors: - otsi 1'1)- Prc� hen toms 4"-
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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: 1 Date: �/ q 1 1
PART 4: Determination of the Hearing Official
0,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:
Hearing Official Signature: Date: 2-��c
J:\EH Forms\Waiver-Appeal Mason County Local Revised 12/1/15
Page 2 of 2