HomeMy WebLinkAboutWaiver Appeal - EH Environmental Healh - 4/9/2002 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
HaalO� Waw Quality liaalth
(360)427-%70
B1IFAIR C�275-0467 &4468
Application fo giver ppeal TOIL.FREE 1-500-562-SM
FAX(360)427-7798
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Instructions
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PART 1: Applicant/Parcel Identification d p
Name of Applicant /� J6 Date
Mailing Address 76 �1 Telephone
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Assessoes Parcel Number :12L1o(o— :Q- OOtblo
Subdivision Name and Lot wilder I n ' N D
PART 2: Nature of Waiver/Appeal LI^ll AP� 0 9 2M
Q qe Sewage Requirements ❑ Food sanitation Requirements
V B pmnitrMewpolkies o Solid Waste VICES
o Locafiat WAC246-2n-09501 ❑ OraupB Water
o Hoj&ng tank WAC 246-272-12501 ❑ water Adequacy Requirem i Is
o OnSite Standards ❑ Fnforcrment 1-tm es din
a Cciifuation owttrmctor(prmrpQ O Other
DcparCmeaffi!DUammanons
designer, uwaller O&Mspec)requi»e=
Description of WaivedAppeal Cmdude Justification.additional material may be attached):
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Date: 19-
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PART 3: Health Department Evaluation (Staff•Use Only)
I B. Type of On-Site waiver Cif aPpGible):
1 A. Type of Determination Required:
O Appeal )(Waiver O None required ❑Chris A 0 Gass B ❑Chss C
Z• Identificatoo of Specific ination Cmdude date of determination or latest
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3. Marine of Appeal-
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4. Hearing OfficaL-
O Board of Health Health Offi=
O pollution Control Herring Board ❑ Health Servioes Director
❑ Certified Contractor Review Board ❑ Environmental Health Manager
5 Mitigating Factors: , �t v L6
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6. !have rzvieedlhis xnitr�Amrmace regvett
Ir is complere,and mitigation r equir ell by state I
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Staffl. F ,
PART 4: Determination of the Hearing Official
has determined that approval of this request will not adversely affect Public health and
The hearing official - -�
Q� and conditions:
�hereby granted 'Iles decision is based on the foQowiug fntdmgs
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O The hearing official has determined that approval of this request could potentially have an I ersely affect
public bealth and is hereby denied. This decision is based on the following fmdrngs
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Date
Hearing
/eU►D.rrXURC-H1Y&t'Af"X i7P U April ss•IM