HomeMy WebLinkAboutWAI2026-00024 - WAI Health Waiver - 4/22/2026 415 N.6"'STREET,SHELTON WA 98584
SHELTON:360-427-9670,ext 400
. . S BELFAIR:360-275-4467,ext.400
Public Health & Human Services
f r VII fiver or A eal l AAR C'�
Ap Ilcatl n o a pp d u
Amount Paid: Receipt Number: 0�
Please note,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. FeesImay 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 Sebastian Gaspar Telephone 360-328-6466
Mailing Address PO BOX 138
City BELFAIR State WA Zip 98528
Parcel No. 1 2 2 3 3 6 4 2 --
0 0 0 4 1
--
Site Address 480 NE Mission Creek Rd
TA 4 OF NW1/4 SE1/4 S 57/28
Subdivision Name and Lot
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
Onsite: Location,WAC246-272A-0210 ❑ Building Permit: EH Review Policies
Onsite: Holding Tank,WAC246-272A- ❑ Appeal:Enforcement Timelines
0240 ❑ Appeal:Departmental Determinations
❑ On ite: Contractor Certification ❑ Other
Re uirements
Description of Waiver/Appeal (include justification, additional material may be attached.):
OSS rqserve area reduced setback from 100' to 75' from a drilled private well, if
future reserve area is used as designed then a BNR 500 to a Pressure distribution
timed ose OSS will a required (TL-B) and vertical separation.
Applicant Signature: Date: 4/2/2026
Revised 03/03/2026
This form may be scan d d available for public view on the Mason County Web site.
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PART 3: P Iblic Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
❑Appeal ' 31Vaiver O Class A ❑Class B ❑Class C Local
11 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 N/A
Hearing Official:
1f Environmental Health Manager ❑ Public Health Director Other:
2. Identification of Specific Code/Standard/Determination (include date of determination or latest
Code/Standard revision): / (,-ZG72-,4- 7 .fQ
3. Nature of�Appeal:
v & vy VtC4c- +v1barn
5. Mitigating Factors:
L € e Q AC " Ve'en
I o�
N
6. I have received this waiver/appeal request. It is complete and mitigation required by the state
and local policy has been submitted. I2
Staff Signature: I Date: 4 fft '
1 1
PART 4: De#termination of the Hearing Official
he 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 hearin 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
0S�
Health Offici I I Signature: Date Ott T 1O Z Revised 03/03/2026
This form may be scanned and available for public view on the Mason County Web site.
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