HomeMy WebLinkAboutWAI Health Waiver - 6/10/2022 01.4"
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rMASON COUNTY
s` al. ' COMMUNITY SERVICES
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y Building,Planning,Environmental Health,Community Health
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415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 {• Belfair: (360)
275-4467
7 ext 400 • Elma: (360)482-5269 ext 400
FAX
Application for Waiver/Appeal
Amount Paid:
Receipt Number:
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 Identification
Name of Applicant L.U!1 wx G&Na-nce,— Telephone 3(&C "- e' o - 7"232
Mailing Address of Applicant Y A 3a 4_ N 1p L
City C L-`I State 1.7/4. Zip '%e S'a 1
12-digit Tax Parcel
No. Z 1 li 0 —i -- 1 Z -- ci 6 3 ck 0
Site Address `IC e • V—-z R-4 A r L4
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 ❑ Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
VI Mason County Onsite Standards 0 Departmental Determinations
❑ Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
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Q- .wl i%t c t23 It.to) Pxl-te-SYI-a wLl. PA-SS.4L.O J✓-f t t=.t 4-T-z:1
kS ✓S or 6to 3e.Za..L%At- AS
Applicant Signature:
Date: G-to--in-
I:/EH Forms:.Waiver-Appeal Mason County Local Revised 1/20/2017
Page I of 2
PART 3: Public Health Evaluation (Staff Use Only) ( o c y'
1. Type of Determination Required: T pe o nsite a ver(if a li able)
Appeal T Vaiver i None required C ss A C Clas 7 Cla
2. Identification of Specific Code/ Standard/ Determination (include date of determination or latest Code/
Standard revision) --75 A-0 51drfe V.(, (�..y
3. Nature of Appeal: ) y
CAA Mitt,Ct +react, w/
4. Hearing Official:
❑ Board of Health 0 Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board lit_ Environmental Health Manager
5. Mitigating Factors:
l�c�r t itiL B 2 G'
6. I have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been itted.
Staff Signature: opt LiAl4A "^' Date: 0 '2-) —2>
PART 4: Determin ion 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: tb
JAEH Forms'.Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of2