HomeMy WebLinkAboutWAI2026-00023 - WAI Health Waiver - 4/3/2026 415 N.6"STREET,SHELTON WA 98584LTON:M
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L AIR:360-27 360-427-4670,ext 400 ext.400
Public Health & Human Services
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Application for Waiver or Appeal
Amount Paid: J 9 Receipt Number: -c �� y I
WAI OO
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 Always Painting & Contracting Telephone Mikey(360)764-3437
Mailing Address 301 E Wallace Kneeland Blvd, Ste 224, PMB 38
city Shelton State WA zip 98584
Parcel No.
Site Address 10 E Barnsby Place, Shelton, WA 98584
Subdivision Name and Lot Lake Limerick #4, Lot 26
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-021 0 ❑ Building Permit: EH Review Policies
❑ Onsite: Holding Tank,WAC246-272A- ❑ Appeal:Enforcement Timelines
0240 ❑ Appeal:Departmental Determinations
❑ Onsite: Contractor Certification O Other
Requirements
Description of Waiver/Appeal(include justification, additional material may be attached.):
Reduce setback from house to drainfield from 10' to a minimum of 2'. Mitigation is
that existing drainfield is down-slope of foundation and effluent will drain away from
house. See septic plot plan attached.
Applicant Signature: Date:
(- Revised 03/03/2026
This form may be scanned and available for p lic view on the Mason County Web site.
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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 ≤I-ocal
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:
VEnvironmental Health Manager ❑ Public Health Director ❑ Other:
2. Identification of Specific Code/Standard/ Determination (include date of determination or latest
Code/Standard revision):
3. Nature of Appeal:
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 policy has been submitted. l �IStaff Signature: Date:
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:
O 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:______________
Revised 03/03/2026
This form may be scanned and available for public view on the Mason County Web site.
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