HomeMy WebLinkAboutWAI2022-00113 - WAI Health Waiver - 9/15/2022 \N1a10-. DoII3
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MASON COUNTY
COMMUNITY SERVICES
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'fy Building,Planning,Environmental Health,Community Health
�J•Ei1ry
03 415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (36'C1$427 67 400 Belfair: (360) 275-4467 ext 400 :• Elma: (360) 482-5269 ext 400
rn FAX (360) 427-7787
bApplication for Waiver/A peal
ro Amount Paid:
viReceipt Number:)4,,?_• S
Instructions i c=
1. Complete Parts 1 and 2. No determination can be made until these parts are fully 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 Identification
I' l - �i � `1
Name of Applicant I G'� 'Tt�J\ ^ �i Telephone <0 .S -C90S
Mailing Address of Applicant O 8 t e_o
City C ` State G a--- Zip 9 70 ! 3
12-digit Tax Parcel No. 2 0 1 -- c 6 -- 0 U 0 6 to
Site Address �' Z l.e ► S 1 Vov. L
Subdivision Name and Lot 75 1 5 "\ /u{-
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
❑ Separation 0 Food Sanitation Requirements
❑ Building Permit Review Policies 0 Group B Water System Regulations
Location, WAC 246-272A-0210 0 Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
❑ Mason County Onsite Standards 0 Departmental Determinations
0 Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
Live L (1)„e , ,5 6, cv\. l(10f
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Applicant Signature: Date: q/ 7/2 Z
J:\EH Fonns1 Waiver-Appel Mason County 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)
Appeal > Vaiver -, None required Class A Class B _ Class C L d C —'
2. Identification of Specific Code/Standard/ Determination (include date of determination or latest Code/
Standard revision) W PALZ`'tC. Z 1 Z A - CZA
3. Nature of Appeal: II
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1) (Ma rk3 Olt 1(i1 lh I C -f-o Quill., t,k/ I J 7 S----14
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: 05
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6. I have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted.
Staff Signature: , 5 Y ' 1 Date: R 12 J Z Z
PART 4: Determination of the Hearing Official
I1. 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: (4/.7/ Date: t/:z 7 -
J:\EH Forms\Waiver-Appeal Mason County Local Revised l/20/2017
Page 2 of 2
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