HomeMy WebLinkAboutWAI2024-00010 - WAI Health Waiver - 1/24/2024 „L:i.,;,;ir MASON COUNTY
;l►. 1 COMMUNITY SERVICES
--,,. - - . Building,Planning,Environmental Health,Community Health
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415 N 6`h Street, Bldg 8, Shelton WA 98584,
Shelton: (360) 427-9670 ext 400 Belfair: (360)275-4467 ext 400 •:• Elma: (360)482-5269 ext 400
FAX (360)427-7787
Application for W iver/Appeal
Amount Paid: �7
Receipt Number: ”(u '`"t
Instructions \A I ig• -ay_ 000kQ l
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�U Y �� Telephone �4 ' %
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Name of Applicant .�('[S / /
Mailing Address of Applicant AGO b• It t l/daLP
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City /4 VI 1,9ik. State Jei Zip 9 5 2
12-digit Tax Parcel No. 3 z / 0 5- -- 4 "1 v - f ® fe/ 3
Site Address /a y` ilei- / ISO' ()IA4OV t()a ` q"SJ a_
Subdivision Name and Lot (1 O`t' -s-p 1,36. A F 4f-2-3 h PTI v rR. 13 -C.
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 ❑ 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 ❑ Departmental Determinations
0 Other
Description of Waiver/Appeal (include�tification,addi�ral material may be attached.):
ro(Are/4-/-t o -r-6 .ego ttrr Ic /S" -7/
Applicant Signature: ._.710.116 .f.ure,.--k-c9 Date: /` v( —2-1—f
Revised 1/20/2017
J:\EH Forms\Waiver-Appeal Mason County Local Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
Appeal :Waiver i None required Class A r Class B Class C
2. Identification of Specific Code/ Standard/ Determination (include date of determination or latest Code/
Standard revision) A /A I �—Z l Z_A
3. Nature of Appeal Se-VCCLAc c` /1, KoULY-
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
0 Certified Contractor Review Board Environmental Health Manager
5. Mitigating Factors: Ul.T-J
6. I have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted.
11/17-1 Date: ( f,zA/Zt_j
Staff Signature:
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:
127/17Y Date: Z,/r/'L
Revised 1/20/2017
J:\EH Forms\Waiver Appeal Mason County Local Page 2 of 2