HomeMy WebLinkAboutWAI2023-00094 - WAI Health Waiver - 9/18/2023 `,N`"n-4_tit
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MASON COUNTY
l� -. COMMUNITY SERVICES
.r, Building Planning,Environmental Health,Community Health
415 N 6th Street. Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 Belfai360) 2 5-4 7 ext 400 •- Elma: (360)482-5269 ext 400
FAX
7
Application for Waiv_ er/4�PPeal
Amount Paid: ����./��f11
Receipt Number. �.t)_._1 00(1) "t"r
Instructions w0 /?)— v U0�4
1. Complete Parts 1 and 2. No determination can be made until these parts are fully comoleted.
2. Feesbmay billed for with attachments to MasonCountyPublic Health forl Health ee review.edule.
3. Submit completed application
PART 1. Applicant/Parcel Identification 42s-sot-o6as
Matthew & Karen Eschbach Telephone
Name of Applicant
6711 103rd Ave NE
Mailing Address of Applicant 98033
Kirkland State WA Zip_________--
City 3 0 O a O t Z
12-digit Tax Parcel No. 3 L 2-
12901 NE Northshore Road- Belfair, WA 98528
Site Address
Madrona Morningside Tracts
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal ❑ Contractor Certification Requirements
(Installer, Pumper, O&M Specialists)
❑ S Reduction in Vertical ❑ Food Sanitation Requirements
❑ Separation ❑ Group B Water System Regulations
❑ Location,Building Permit 246-27 Policies0 0 Water Adequacy Requirements
0 ligWAC WAC 24 272A- ❑ Enforcement Timelines
❑ Masonsing Tank to Standardsadrds40 ❑ Departmental Determinations
❑ County Onsite ❑ Other
Description of Waiver/Appeal (include justification, additional material may be attached ):J,Cr' c
e.
ru _r Jib 3 p�. AV'�1 n �,
U-2dC n "(• -
Date
Applicant Signature. g741 U
Revised 1/20/2017 Page I of2
1-.fEH Forms\Waiver-Appeal M on C nt lu
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination�� Required: Type of Onsite Waiver(if applicable)
///
r Appeal Waiver r None required - Class A Class B r Class C L�Z
2. Identification of Specific Code/ Standard) Determination (include date of determination or latest Code/
Standard revision) v\/-{ti'L2`'(.6 2_A--0Zl.t7
3. Nature of Appeal: \CO-01-.ccce— f A__„ rt
4 w+
4. Hearing Official: �J w^
O Board of Health ❑ Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board g, Environmental Health Manager
5. Mitigating Factors: 1 PkVA 41 J rut- ueSv _/Y
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: Y'W v p Date: 113(V-1 (t_3
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. "N V Date: /O/Z 5�u
J:vIll Forms A Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of2
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