HomeMy WebLinkAboutApplication for Waiver/Appeal - SWG Application - 3/25/2011 MASON COUNTY PUBLIC HEALTH
415 N 6 h STREET.,PO BOX 1666,SHELTON,WA 98584
SHELTON(360)427-9670,Ext:352, ELMA(360)482-5269, BELFAIR(360)2754467
WEB: ham://www.co.mason.wa.us FAX:(360)427-8442
Application for Waiver/Appeal
Amount Paid:
Receipt Number.
Instructions h W lot
1. Complete Parts 1 and 2.ko deta4unation can be made until these parts are Billy completed
2. Fees may be billed for waivers and appeals,based on the Environmental Health Fee Schedule
3. Submit completed application with attachments to Mason County Public Health for review.
PART 1.APPLICANT/PARCEL IDENNTIFIC�ATION
Name of Applicant /7*4 u��✓ Telephone -360-!5&dSd�-
Mailing Address of Applicant p*91T y2 9
City 0714G/11,C 4 State kfA- Zip 261
12-digit Tax Parcel No. -42'- Z 3 v - S l -- 'S d
Site Address / F
Subdivision Name and Lot e f SLX-S
PART 2: Nature of Waiver/Appeal
Class B Reduction in Vertical Separation ❑ Food Sanitation Requirements
Building Permit Review Policies ❑ Group B Water System Regulation
❑ Location,WAC 246-272A-0210. ❑ Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Onsite Standards ❑ Departmental Determinations
❑ Contractor Certification Requirements -is- Other
(Installer,Pumper,O&M Specialists)
Description of Waiver/Appeal(include justification,additional material may be attached.):
Cirr,-�P�✓ Silt a� Lo� S�-LL
Applicant Signature- Date: 2S
Page 1 of 2 Updated 4l22/2009
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if app cable)
❑ Appeal pg�Waiver ❑None required ❑ Class A ❑ Class B ❑ Class C
2. Identification of Specific Code/Standard/Determination(include date of detPrminati(nor
latest Code/Standard revision)
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3. Nature of Appeal:
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board ;' Environmental Health Manager
5. Mitigating Factors:
r-b-4 11Y C-60Le1�
6. I have received this waiver/appeal request. It is complete and mitigation required by a state
and local policy has been submitted.
Staff Signature: C�� d,fi _ Date: y / L
PART 4: Determination of the Hearing Official
The hearing official has determined that approval of this request will not adversely affect 1 ublic
health and is hereby granted. This decision is based on the following findings and conditions:
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The hearing official has determined that approval of this request could potentially adversely effect
public health and is hereby denied. This decision is based on the following findings and
conditions:
Hearing Official Signature Date:
Page 2 of 2 Updated 4I22/2009