HomeMy WebLinkAboutWAI2026-00019 - WAI Health Waiver - 3/25/2026 415 N.6th STREET,SHELTON WA 98584
• MASON COUNTY SHELTON:BELFAIR:360-275-4467,ext.400
Public Health & Human Services
Application for Waiver or Appeal
,�Amount Paid: S Receipt Number: � _(1 L 18....J
WAI �-O3 b - bpO\c
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 ! II'1W ( &'c ice, 1B{tJ(9' frgo() Telephone 3(0 701 Olga
Mailing Address Q vaLk .n £'
City State IWIL. Zip $≤$ S�
Parcel No. L ? 3 -- (L -- ..i2 0 Z 7
Site Address 1' a k6c fit ¢�[� cQ✓ M\ Jc.x 3 ' -
Subdivision Name and Lot 11J7([?
PART 2: Nature of Waiver/Appeal JJ1] MAR 23 2026
❑ Onsite: Class A Waiver O Food Sanitation Requ r ents
❑ Onsite: Class B Waiver ❑ Group B Water Syste
❑ Onsite: Class C Waiver ❑ Water Adequacy Requirements
J1 Onsite: Location, WAC246-272A-0210 ❑ Building Permit: EH Review Policies
❑ Onsite: Holding Tank,WAC246-272A- ❑ Appeal:Enforcement Timelines
0240 O Appeal:Departmental Determinations
❑ Onsite: Contractor Certification ❑ Other
Requirements
Description of Waiver/Appeal (include justification, additional material may be attached.):
f'�r
Applicant Signatur Date: 3
Revised 03/03/2026
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 `,Waiver ❑ Class A ❑Class B ❑Class C ocal
l State Waiver Criteria
Number of Bedrooms: Nitrogen Treatment: ❑Yes ❑ 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
Heari g Official:
Environmental Health Manager ❑ Public Health Director ❑ Other:
2. Identification of Specific Code/ Standard/ Determination (include date of determination or latest
Code/Standard revision): rf !J -'t C-277.,4-.OT:[O
3. Nature of Appeal:
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5. Mitigating Factors:
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6. I have received this waiver/appeal request. It is complete and mitigation required by the state
and local poli has been submitted.
Staff Signature: Date: 3 I I7i�
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: 3 Z✓' �'
Revised 03/03/2026
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2