HomeMy WebLinkAboutWAI2026-00038 - WAI Health Waiver - 5/12/2026 415 N.6th STREET,SHELTON WA 98584
` SHELT0N:360-42 - 70,ext 400
• MASON COUNTY BELFAIR:360-2 400
Public Health & Human Services
Application for Waiver or Appeal \\
Amount Paid: Receipt Number: oL'�'�p
WA! co o -
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 maybe 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 Nicholas Browne Telephone 3602993516
Mailing Address 2400 W Skokomish Valley
city Shelton State WA Zip 98584
Parcel No. 4 2 1 0 8 -- 4 3 -- 0 0 0 1 0
Site Address 2400 W Skokomish Valley
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
❑ Onsite: Class A Waiver ❑ Food Sanitation Requirements
❑ Onsite: Class B Waiver O Group B Water System Regulations
❑ Onsite: Class C Waiver O Water Adequacy Requirements
Onsite: Location,WAC246-272A-021 0 O Building Permit: EH Review Policies
❑ Onsite: Holding Tank,WAC246-272A- O Appeal:Enforcement Timelines
0240 O Appeal:Departmental Determinations
❑ Onsite: Contractor Certification ❑ Other
Requirements
Description of Waiver/Appeal (include justification, additional material may be attached.):
As built septic drain field 8ft from building foundation. Regulations prohibit moving
footprint. Please see attached foun a ion drainage plan approved y MAson County
via emial. Finished grade will slope away from foundation toward drairifleld as
required.
Applicant Signature: Date: 5/7/2026
Revised 03/03/2026
This form may be scanned and vailable 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 O Class A ❑Class B ❑Class C Local
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 O No N/A
Hearing Official:
IEnvironmental Health Manager ❑ Public Health Director ❑ Other:
2. Identification of Specific Code/ Standard/ Deter ination (include date of determination or latest
Code/Standard revision): �j? Z( 0
3. Nature of Appeal:
5. Mitigating Factors: to
& f r'lOt rJ 'TF
6. I have received this waiver/appeal request. It is complete and mitigation required by the state
and local polic has been submitted. b�
Staff Signature: Date: v
/24
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: DateriT 2/2 G
Revised 03/03/2026
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
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