HomeMy WebLinkAboutWAI2026-00054 - WAI Health Waiver - 7/1/2026 415 N.6th STREET,SHELTON WA 98584
• MASON COUNTYSHELTON:360-427-9670,ext 400
BELFAIR: 4467,ext.400
Public Health & Human Services
Application for Waiver or Appeal �
Amount Paid: Receipt Number: Q2 p
7
WAI 7 O Z&OO f
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. 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 TODD FREESE Telephone (360) 951-9556
Mailing Address 1910 East 4th Ave #235
city OLYMPIA State WA Zip 98506
Parcel No. 2 2 0 3 2 -- 5 0 -- 0 0 0 0 7
Site Address 461 SE ARCADIA SHORES RD
Subdivision Name and Lot N/A
PART 2: Nature of Waiver/Appeal
El Onsite: Class A Waiver ❑ Food Sanitation Requirements
El Onsite: Class B Waiver ❑ Group B Water System Regulations
❑ Onsite: Class C Waiver El Water Adequacy Requirements
❑ Onsite: Location, WAC246-272A-0210 El Building Permit: EH Review Policies
❑ Onsite: Holding Tank, WAC246-272A- El Appeal: Enforcement Timelines
0240 ❑ Appeal:Departmental Determinations
❑ Onsite: Contractor Certification ❑ Other
Requirements
Description of Waiver/Appeal (include justification, additional material may be attached.):
REDUCTION IN DRAINFIELD SETBACK TO SURFACE WATER FROM 100FT TO
75FT BY USING INCREASED TREATENT
Applicant Signature: Date: 06/25/2026
Revised 03/03/2026
This form may be scanned and available for public 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 Local
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 6N/A
Hearing Official:
❑✓ Environmental Health Manager ❑ Public Health Director ❑ Other:
2. Identification of Specific Code/Stand rd/ Determination (include date of determination or latest
Code/Standard revision): (�� 777Jr-bZ/d
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 policy has been submitted.
Staff Signature:_ Date: 11( 114
PART 4: Determination of the Hearing Official
A.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:
Revised 03/03/2026
This form may be scanned and available for public view on the Mason County Web site.
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