HomeMy WebLinkAboutWAI2026-00069 - WAI Health Waiver - 8/12/2026 415 N.6`"STREET,SHELT0N WA 98584
MASON COUNTY 3604
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Public Health & Human Services �
AUG 1 1 2026
Application for Waiver or Appeal
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PI M all approved O.slte Waivers have are same expiration date as their OSS Pemd6.
Instructions:
1. Complete Parts i and 2. No determination can be made until these parts are fully comoletetl.
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 Freedom Lane LLC Telephone 253-230-5202
Mailing Address 2226 Eastlake Ave E, #310
City Seattle State WA Zip 98102
Parcel No. 3 1 9 0 7 __ 5 0 00 1 4 0
Site Address 180 W. Freedom Ln, Shelton, WA 98584
Subdivision Name and Lot Madrona Park Lot 14
PART 2: Nature of Waiver/Appeal
❑ Onsite. Class A Waiver O 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 O Appeal:Departmental Determinations
❑ Onsite: Contractor Certification ❑ Other
Requirements
Description of Waiver/Appeal(include justification, additional material may be attached.).
Waiver of 10 ft set-back between home to septic reserve to be 2 ft.
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Applicant Signature I.G'//i5ld/ 211t/C. Date: 07-31 -2026
Revised 0303,2026
This form may be scanned and available for public view on the Mason County Web site.
Pace 1 or3
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
��❑Appeal Vaiver ❑Class A ❑Class B ❑Class C local
1 State Waiver Criteria
Number of Bedrooms:_ Nitrogen Treatment: ❑Yes ❑ No
Soil Type: Minimum Lot Size: sq.fi.
Water Source:l]Public []Private This Lot Size: sq.fi.
Is This Lot Eligible for State Waivers: ❑Yes 0 No N/A
Hearing Official.
Environmental Health Manager ❑ Public Health Director ❑ Other:
2. dentification of Specific Code/Stangar !Determination (mclutle date of determination or latest
Code/Standard revision): Wc&j17T..PC2TI,A=07i1O
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: ZI Tit
PART 4: Determination of the Hearing Official
E 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: DateZ 7
Revised 03.032026
This form may be scanned and available for public view on the Mason County Web site.
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