HomeMy WebLinkAboutWAI2023-00002 - WAI Health Waiver - 12/19/2022 MASON COUNTY
. .. COMMUNITY SERVICES
Building,Planning Environmental Health,Community Health
415 N 6`` Street,Bidg 8, Shel:cn WA 98584,
Shelton: (460)427-9670 ext 400 4i Belfair, (360)275-4467 ext 400 ❖ Elma: (360)482-5269 ext 400
FAX (360)42 7-T787
•
Application for Waiver/A peal
Amount Paid: I
Receipt NLmber: a3 -C x *
Instructions
1. Complete Par.s 1 and 2.No determination can be made until these parts are fully completed.
2. Fees may be billed for waivers and appeals, based cn the Environmental Health Fee Schedule.
3. Submit completed application with attachrr.ents to Mason County Public Health for review.
PART 1. Applicant/Parcel Identification
Name ofApptican: =r;;rF.Y:,;�;;rE Teieprione
Mailing Address of Applicant 1208 FAIRMOUNT AVE
City SHELTON State V/A Zip 98584
':2-digit Tax Parcel No 2 2 2 2 - — 1 - C - � C s
Site Address xX TM DRIVE
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
0 Contractor Certification Requirements
❑ Class B Reductaor i't Vertical (Installer, Pumper, O&M Specialists)
❑ Separation 0 Food Sanitation Requirements
O Bu Cing Permit Review Policies 0 Group B Water System Regulations
tit Location,WAC 246-272A-0210 0 Water Adequacy Requirements
❑ Hol3'ng Tani(WAC 246-272A-0240 0 Enforcement Timelines
❑ Mason County Onsite Standards ❑ Departmental Determinations
0 Other
Descr;pt.on of Waiver/Appeal(include justification, additional material may be attached.):
REDUCE SETBACK 0/F TO PROPERTY LINE. REDUCE SETBACK TANKS TO PROPERTY LINE
REDUCE SETBACK D/F TO FOUNDATION
PROPERTY LINE ANO FOUNDATION NOT DOV1►@GRAD:ENT. LOT IS FAIRLY LEVEL FOUNDATION IS SLAB ON GRADE
WITH`>O S7 E:rS VFPY LAIITEC ON SPACE FOR OSS PPO✓OS6d f 1AIWTAINS ALL OTHER SETBACKS
Applicant gat nne w 5 ?yi tf-t14 Date: 1 I '7(73
JAEH Forms‘'Waiver-Appeal M. ui CoLary Local Revised 1/20/2017
Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable) /—c>G S,(
L Appeal Waiver None required Class A i Class B Class C
2. Identification of Specific Code/Standard/Determination (include date of determination or latest Code/
Standard revision) �f AVV4 l L'
3. Nature of Appeal:
4Qj2 1\, -62_ yfrt°! {.
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
O Certified Contractor Review Board . Environmental Health Manager
5. Mitigating Factors:
90 -ci.k cANick -F La+ i CD 1V-Ft S lA
6. I have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted.
Ck2t1Staff Signature: 41YVI Date:
PART 4: Determination of the Hearing Official
gL 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:
❑ 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: 9 � Date: Z'//% ` 'tom
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of 2