HomeMy WebLinkAboutWEC04-00230 Water Adequacy Waiver - VAR Application - 11/10/2004 �w MASON COUNTY LRECEIVED
DEPARTMENT OF HEALTH SERVICES15-
Environmental Health Water Quality 4ZO W. LtVAR 4ersoealth
LOCAL(360)427-9670
Application for Waiver/Appeal BELFAIR(360) 275-4467&4468
TOLL FREE 1-800-562-5628
1�- FAX (360)427-7798
Amount Paid:
r
Receipt Number.
Instructions
I. Complete Parts I and Z. No determination can be made until these parts ate MIX cpmnleted-
2. Fees may be billed for waivers and appeals,based on the environmental health fee schedule.
3. Submit com leted application,with attachments to the health department for review.
PART 1: Applicant/Parcel Identification
Name of Applicant �T�pl-
t' t Ul N /Date t O `4
Mailing Address 1J- SV�4)t4 ftW `telephone
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Assessor's Parcel Number P;�L �2
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
❑ On-Site Sewage Requirements ❑ Food Sanitation Requirements
❑ Buildingpermitreviewpolicies ❑ Solid Waste Requirements
❑ Location, WAC 246-272-09501 ❑�+ Group B Water System Requirements
❑ Holding tank WAC 246-272-12501 (E Water Adequacy Requirements
❑ On-Site Standards ❑ Enforcement Timelines
❑ Certification contractor(pumper, ❑ Departmental Determinations
designer, installer, O&Mspec)requirements ❑ Other
Description of Waiver/Appeal(include justification,additional material may be attached):
Applicant Signature. Date:
H I WDATAURCHIVEMAIVEP WP Update:April 25,1997
S D,
PARII3: Health Department Evaluation (Staff Use Only)
IA. Type of Determination Required: 1B. Type of On-Site Waiver(if applicable):
❑ Appeal ❑ Waiver ❑None required ❑ Class A ❑ Class B ❑ Class C
2. Identificaton of Specific Code/Standard/Determination(include date of determination or latest
code/standard revision):
Water adequacy policy
3. Nature of Appeal:
Receive building permit prior to well being drilled.
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:
A) WEC# Lout —00 Z30
13) DOE# W 186 118
C) Two vicinity well logs
D) Letter from well driller
E) Condition permit: Well log and satis bacti to be submitted prior to occupancy.
6. I have reviewed this waiver/variance request. /t is complete, and mitigation required by state and local
policy has been submitted.
Staff: Date:
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:
�tf U caw
❑ 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:
Hearing Official Date: 1
H:I WAIVER.WP.DOC Update:November 23,1998