HomeMy WebLinkAboutWAI Health Waiver - 2/23/2023 i,i--_'" � 415 N.6`h STREET,SHELTON WA 98584
s\ MASON COUNTY SHELTON:360-427-9670,ext 400
1,14111 E. '61 COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400
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\�,�; �'' / Building.Planning.Environmental Health,Communityhealth ELMA:3G0FAX 52G9,27-7790
'li ,ILAO_�' FAX:3G0-427-7798
Application for Waiver or Appeal
Amount Paid: Receipt Number:
WAI -
Instructions:
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 Information
2S3. 2- ' 1Cj << < r
Name of Applicant pave, .5 i!ju1f5GYl Telephone 753, 261 -SOS
Mailing Address 7 0 . 130x I e 6 Z,
City 13(LC kJI C y State k/I f Zip ?83 L
Parcel No. 61 / 7 7 , 6 -- S _ -- 0 O 1 -2- 2_
Site Address I Z 1 IV B too t( t oa, - ll ood s pori
Subdivision Name and Lot take_ ((jS UI 1/f0rl 0 12 1 R 1 Z Z,
PART 2: Nature of Waiver/Appeal
❑ Onsite: Class A Waiver ❑ Food Sanitation Requirements
❑ Onsite: Class B Waiver 0 Group B Water System Regulations
❑ Onsite: Class C Waiver ❑ Water Adequacy Requirements
0 Onsite: Location, WAC246-272A-0210 ❑ Building Permit: EH Review Policies
❑ Onsite: Holding Tank,WAC246-272A- 0 Appeal: Enforcement Timelines
0240 0 Appeal:Departmental Determinations
D Onsite: Contractor Certification ❑ Other
Requirements
i Description of Waiver/Appeal (include justification, additional material may be attached.):
Tfke, locc1 .(ibvl of -Ike, $ -1,r cfrat4ftefr/ Is less ±ho�1
tO ff I -ran -11p, 1)OM ;'s 'dunce (Itu(\ RP ves U/,At t �o
educe 'he Se bc'c'lc lci 51 f
Applicant Signature: 4, 41.11 fib_ Date: 2 ' 2 / 23
Revised 8/13/2018
This form may be scanned and available for public view on the Mason County Web site.
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PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver (if applicable)
Appeal :;1 Waiver ; None required Class A : Class B Class C l l(
2. Identification of Specific Code/ Standard/ Determinationm (include date of determination or latest Code/
Standard revision) it/4c Zi(C • Z I Z11- 10
3. Nature of Appeal:
ne/u Ci nti 17&rre $ ittla a{enn tC dra,n r'(! /, S
4. Hearing Official:
❑ Board of Health 0 Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
O Certified Contractor Review Board i( Environmental Health Manager
5. Mitigating actors:
l r co n f f�(r;( �� .� ���>^a cht'�� fr0al 1ii trust
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: A Date: 2 l re( 7Cl 2.
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:
❑ 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: E/L 4,2.E
J:AEH Forms\Waiver-Appeal Mason County Local Revised 1/20,2017
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