HomeMy WebLinkAboutSWG Application - 5/6/2004 MASON COUNTY
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DEPARTMENT OF HEALTH SERVICES
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Water Quality
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emnm— LOCAL(360)427-%70
pplication for Waiver/Appeal BBL TOLL FREE 1-800-562-5628
A FAIR(360)275-4467&4468
FAX(360)427-7798
Amount Paid.•
Receipt Number:
Instructions
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PART 1: Applicant/Parcel Identification t
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Name of Applicant �S o L`►� r Port
Telephone
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Marlin Address � l`- � A
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Assessor's Parcel Number 02
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Subdivision Name and Lot
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PART 2: Nature of Waiver/Appeal �OOZ t 0 01
❑ Food Sanitation R u �x
Q On-Site Sewage Requirements ❑ Solid Waste
❑ Building permit review policies ❑ Group B Water System Requirements
M--rocation, WAC 246-272-09501 ❑ Water Adequacy Requirements
❑ Holding tank WAC 246-272-12501 ❑ Enforcement Timelines
❑ On-Site Standards ❑ Departmental Determinations
❑ Certification contractor(pumper. ❑ Other
designer, installer. O&Mspec)requirements
Description of Waiver/Appeal(include justification,add* ional material may be attached): a n
� Date:
Applicant Signature:
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H:IWD.IT.(L4RCK1VElWA1VERWP UpQatc:Ape-1u'1997
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PART 3: Health Department Evaluation(Staff USe OIt ,
i A. Type of Determination Required: l B. Type of on-Site Waiver(if applicable):
O Appeal *Waiver ❑None required ❑Class A ❑Class B ❑Class C
2. Identificaton of Specific Code/Standard/Determination(include date of determination or latest
codelstandard revision):
tN,�-c 2,k to
I Nature of Appeal:
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ pollution Control Hearing Board ❑Health Services Director
❑ Certified Contractor Review Board ❑Environmental Health Manager
5 Mitigating Factors:
2 �C
6. 1 have reviewed this waiver/variance request. It is complete, and mitigation required by state and local
policy has been submitted.
Date:
Staff.
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 have an adversely affect
public health and is hereby denied. This decision is based on the following.findings:
Date:
Hearing Official
U.MDATAURCXIVEMAIVEk hT Update:Apnt 25.1997