HomeMy WebLinkAboutRequest for Waiver from State Regulations - SWG Application On-Site Sewage Systems (Chapter 246-272 WAC)
Request for Waiver From State Regulations
Section I. (completed by applicant)
Name. (1) /�I J / Local Health Department/District (2)
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Address: ---_ _._--
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Telephone: U60 ) T 7,V ,j 3y7-
Signature:
Property Identification: (3)
Section IL (completed by applicant)
WAC Number (4) WAC Requirement: S) / Waiv r Sought: (6)
246-272 ------- ----___
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Subsection: 62 f tr 7
Justification(mitigation measures to be provided): (7)
Section III. (completed by health officer)
Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9)
Comments/Conditions: (10)
Type of Waiver: (11) TC lass ] Class BCClas-s-Z�am-Request DOH review before granting? Yes_ No,
Neighbor Notification: (12)
Required? Yes_ No x If needed, are agreements, easements, etc.properly filed? Yes _ No
Section IV. I (completed by health officer)
This Request For Waiver From State Regulations has been reviewed according to the provisions of Chapter 246-272 WAC On-Site
Sewage Systems. The review criteria applied,and the mitigation measures proposed and/or required,have been evaluated for their ability
to provide public health protection at least equal to that provided by this chapter WAC.
] Denied A ApproveRl7 -anted—Subject to all comments,conditions and requirements noted in Sections II and III.
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Local Health Officer (13) 4 Date: