HomeMy WebLinkAboutWAI2023-00020 - WAI Health Waiver - 3/2/2023 •
-., MASON COUNTY
= rim COMMUNITY 1 SERVICES
yii ,,;7 Building,Plann ing,Environ mental Health,Community Health
415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 ❖ Belfair: (360) 275-4467 ext 400 i Elma: (360)482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal D T 11 (VI
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Amount Paid: I ctd• —
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Receipt Number: al MAR 0 2 2023
Instructions By kW
I 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 1-orrAiot 1 a tit 5 Telephone ? O 3 0 q - t d ct3
Mailing Address of Applicant /ZO SCn.hrNy In It \'dk U3
City Ct_racr4-ov\ State 1JJ Zip g 1 g 1 Q.
12-digit Tax Parcel No. 3 a 2 a q -- 5 a - O O 1
Site Address 4,0 J WE M of i'ne_ V+aJ Or , e \ j r
Subdivision Name and Lot
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
le" Mason County Onsite Standards 0 Departmental Determinations
❑ Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
Pc4SSWY__ 1�e), So;\ T`I az- LI
Applicant Signature: ' 4-ekir Date: a/ F-c5 009,3
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)
o Appeal ?(Vaiver
o None required EElass A ❑ Class B o Class C
2. Identification of Specific Code/Standard/Determination (include date of determination or latest Code/
Standard revision)
3. Nature of Appeal: ad ill Sid -f�/
11/ e
4. Hearing Official:
❑ Board of Health 0 Health Officer
O Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board 0 Environmental Health Manager
5. Mitigating Factors:
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: Lib
IMAL---\ Date: ?—z3
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:
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of 2
Granting Waivers from State On-Site Sewage System Regulations Chapter 246-272A WAC
Effective Date: July 1,2007 Revised April 2017
On-Site Sewage Systems (Chapter 246-272A WAC)
Request for Waiver from State Regulations
Section I. I (completed by applicant)
Name: (1) I Local Health Department/District (2)
L0rC(n;Ae, Jt cedes (see instructions)
Address: k•11 /J
/Z0 SGnr s 1C
&temarfoo LU, il,S12
Telephone: (340 ) Soq- /0�33
Signature: .0 % -2 _y
Property Identification: (3) /00 NE Moue^:(, Vt ec,,, �(_ , K ct i L,,r
earta # 3a,a.ak•SZ• p20/8• —
Section II. (completed by applicant)
WAC Number: (4) WAC Requirement: (S) Waiver Sought:p (6)
246-272A—Oa3`i(31 (�. dtd5only deSjrxti M Scl'( Trams 1-3 P`cSSurc 'gt14.tn Soi( l`(pc `
Subsection:
Justification(mitigation measures to be provided): (7)i-rta+se e4_. I...Luc.t 6 (t.it �4 cilstA 0cc4 c �u«
for" -
At S{`f v bah o A EA) 'Lt., 0-A- feast' a.L{ 1 re-(n•-S o f VL f K.,-` St f ore4:o IN
Section III. (completed by health officer)
Review Criteria: (8) Mitigation Measures(in addition to those prposed): (9)
0 t/VL piVj,ce >Cckr(y
Dry 11Z- r L tv5V-' I/at re -,/
Comments/Conditions: (10)
Type of Waiver: (11) ( ass A [ ]Class B [ ]Class C—Request DOI I review before granting? Yes_ No
Neighbor Notification: 2) Required? Yes No_ If needed,are agreements,easements,etc.properly filed? Yes _ No_
Section IV. (completed by health officer)
This Request For Waiver From State Regulations has been reviewed according to the provisions of Chapter 246-272A WAC On-Site
Sewage Systems. The review criteria applied,and the mitigation measures proposed and/or required,have been evaluated for their ability
to provide public health protection at least equal to that provided by this chapter WAC.
[ ] Denied [p4Approved/Granted—Subject to all comments,conditions and requiremen noted'n Sections It and III.
Local Health Officer (13) '^ Date: 1--
DOH 337-021 Page 26 of 32