HomeMy WebLinkAboutWAI2022-00134 - WAI Health Waiver - 12/8/2022 r•t,t v.
:r MASON COUNTY
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t COMMUNITY SERVICES •
Building,Planning,Environmental Health,Community Health
415 N 6th Street, Bldg 8,Shelton WA 98584, ^°
Shelton: (360) 427-9670 ext 400 ❖ Belfair. (360)275-4467 ext 400 •� Elma: (360)482-5269 ext 4 0 rcl c4
FAX (360)427-7787 ^'
Application for Waiver/Appealr"
Amount Paid: 1 po
Receipt Number: 2022- O' °tS9
Instructions \N 2.022_ V9--k
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 ``
Name of Applicant `. re S Telephone ,k-PU - C.) 1 - R 7O1
Mailing Address of Applicant 2 • (-i ( 62,66AnAo ck,., }. r_l•�--
City C O( - 5\oc State t)-` A' Zip qM, ,7Q
12-digit Tax Parcel No. Z Z 3 3 (D -- S -- Q . �(
Site Address aS_5‘C1/4?-0+ \AVc
Subdivision Name and Lot <iv\C \IN C (Ai 1 p ef 9
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
cr Separation ❑ Food Sanitation Requirements
❑ Building Permit Review Policies Cl 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
❑ Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
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Applicant Signature: Date: I - /- Z 2--
J:\EH Forms\Waiver-Appeal 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 Ncpaiver ❑ None required o Class A o Class B ❑ Class C L, ( !V t-
2. Identification of Specific Code/Standard/Determination (include date of determination or latest Code/
Standard revision) , 7itb-Z'7Z A 'O ? L,
3. Nature of Appeal:
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4. Hearing Official:
❑ Board of Health 0 Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board Environmental Health Manager
5. Mitigating Factors: 01104AA-y l 441eActc,14--)--- f is 01 A-6,2 c(
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: \41/1 Date: 1 I7:
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:
0 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: Y4F Z2
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of 2