HomeMy WebLinkAboutWAI2023-00057 - WAI Health Waiver - 6/5/2023 .eh STREET,SHELTON WA'.
584
w .Y MASON COUNTY 415 NSHE SHELTON:360-427 96 0 ext8400
3 •I I' } COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400
`l, �� ELMA:360-482-5269,ext.400
Building Pla m n•:nnrL Erronmen!al Health.Commun,ty Health
�''"�•„Iwo'``~ FAX:360-427-7798
Application for Waiver or Appeal
Amount Paid: Ai a.65 Receipt Number:
WAl . .Da-s - Dobsq-
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 (,
Name of Applicant \ I{.V(� r 'L� r �J,-.k,A 1 Telephone z cc. — 5 `1 ei— 9 ?O o
Mailing Address 111 O . c- ( )C- )(.t,
City &t `\ State l^''`,A Zip q 0 5
Parcel No. 2_ 1_ 0 I C - 7 (c, -- a Cs C 2 0
Site Address e - 2v\ L,-au". L,A t s k( k--c, ;,N ((,�f' -,
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal ( __._
,..._.: \
�I
se Class B Reduce Vertical Separation 0 Food Sanitation Requirements v
❑ Building Permit Review Policies 0 Group B Water System Regulations L.
O Location,WAC 246-272A-0210 0 Water Adequacy Requirements o
❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
❑ Mason County Onsite Standards 0 Departmental Determinations v
❑ Contractor Certification Requirements 0 Other VA
(Installer, Pumper, O&M Specialists) m
Description of Waiver/Appeal (include justification, additional mat ' be attached.):
REDUCE VERTICAL SEPARATION FOR CONVENTIONAL RAVI v OR PRESSURE OSS
CLASS B WAIVER CHECKLIST
RECORDED DECLARATIO OF ATTENUATION ZONE
///
Applicant Signature: Date: _ 5- z 3-Z,3
Revised 8/21/2017
This form may be scanned and available for public view on the Mason County Web site.
Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver (if applicable)
Appeal v/Waiver r None required Class A ✓Class B Class C
2. Identification of Specific Code/ Standard/ Determination (include date of determination or
latest Code/ Standard revision): WAC246-272A-0230, TABLE VI
3. Nature of Appeal:
REDUCE VERTICAL SEPARATION REQUIREMENTS FOR CONVENTIONA GRAVIT OR
PRESSURE OSS. —
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board ®' Environmental Health Manage
5. Mitigating Factors:
CLASS B WAIVER CHECKLIST(MEETS ADDITIONAL REQUIREMENTS OU WITHIN)
RECORDED DECLARATION COVENANT FOR OSS ATTENUATION Z AFN 2t♦�'(�/
6. I have received this waiver/appeal request. It is complete and mitigation required by the
state and local po has been submitted.
Staff Signature: W t`^''ir Date:
PART 4: Determinat' n of the Hearing Official
0- 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:
Health Official Signature: Date: (A 2 /2 i
Revised 8/21/2017
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2