HomeMy WebLinkAboutSWG2008-00026 Application for Waiver/Appeal - SWG Application - 4/14/2008 MASON COUNTY
PUBLIC HEALTH
PO BOX 1666 SHELTON WA 98584
SHELTON (360)427-9670
FAX (360)427-8442
ELMA (360)482-5269
BELFAIR (360) 275-4467
Application for Waiver/Appeal
_
Amount Paid, � _L�----
Receipt Numbers 02
Instructions
=2. Submit
Parts 1 and 2. No determination can be made until these parts are fully completed.
ompleted application,with attachments to the health department for review.
aiver fee of$110.00
Vov_�
PART 1: Applicant/Parcel Identification
Date .4
Name of Applicant
Mailing Address
Z Telephon�36-&'
Assessor's Parcel Number
7
Subdivision Name and Lot 1� I��-r '�' �` "
PART 2: Nature of Waiver/Appeal
❑ Food Sanitation Requirements
❑ On-Site Sewage Requirements ❑ Solid Waste Requirements
❑ Building permit review policies
❑ Location, WAC 246-272-09501 ❑ Group B Water System Requirements
❑ Water Adequacy Requirements
❑_ �Holding tank WAC 246-272-12501 0 Enforcement Timelines
EV Un-Site Standards 0 Departmental Determinations
❑ Contractor certification requirements ❑ Other
(Installer,Pumper, O&M Specialist)
Description of Waiver/Appeal(include justification,additional material may be attached): a line
n,.�•.,.o +t,p sPntic tanks set back of 50 feet_down�o�3'fPet from the high
tide line.l� 11 from the prop p erty lines for the
3. Reduce the setback of 5 feet down to 2 feet
reserve rlp Ines.
Date:
Applicant Signature:
Updated:01-9-2008
Page I of 2
PART 3: Health Department Evaluation (Staff Use Only)
IA. Type of Determination Required: 113. Type of On-Site Waiver(if applicable):
❑Appeal �Gaiver ❑None required Class A ❑ Class B Class C
2. Identification of Specific Code/Standard/Determination(include date of determination or latest code/standard
revision):
3. Ngure of Appet j) r• 7V- r;j�l��
1 --fv 2' , , U r_ -k'
4. Hearing Official:
❑Board of Health ❑Health Officer
[3 Pollution Health Services Director Pollution Control Hearing Board �Environmental Health Manager
[3 Certified Contractor Review Board
5 Mitigating Factors: S U;L - U
b .4 /z,� , I
�r
(. �I have r9viewe `his waiver variance request. It is complete, and mitigation required by state and local policy
has been submitted.
� �:�
Date:
Staff:
Lq(a_
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
ly 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 �"�"'�
Upda
ted:ted:Ol-9-2008
Page 2 of 2