HomeMy WebLinkAboutWAI2023-00112 - WAI Health Waiver - 11/14/2023 111111111111111111
415 N.6th STREET,SHELTON WA 98584
MASON COUNTY SHELTON:360-427-9670,ext 400
COMMUNITY SERVICES BELFAIR: 360-275-4467,ext.400
ELMA: 360-482-5269,ext.400
/ Building,Planning,Environmental Health,Community Health FAX: 360-427-7798
Application for Waiver or Appeal '1 � `
Amount Paid: a 5 Receipt Number: �)'� "OS ouy
Nov 141023
WAI `9-) - l� I I, 0-- RECEIVED
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 7A'!V'O A) txy t. l30 S 1 4 1ephone 'A'C ._75$ • goS
Mailing Address 3vt:J ��C:t ti f i`�5 14)M S L A 1 S
City I(4M WAT 42- State WA Zip 9)3 4 D)
Parcel No. 2 1 -- 1 -- Q C C) `t C
Site Address l 616 L Z- tit)
Subdivision Name and Lot
NOV 14 2023
PART 2: Nature of Waiver/Appeal L
❑ Onsite: Class A Waiver 0 Food Sanitation Requirements
❑ Onsite: Class B Waiver ❑ Group B Water System Regulations
❑ Onsite: Class C Waiver 0 Water Adequacy Requirements
Onsite: Location, WAC246-272A-0210 0 Building Permit: EH Review Policies
Onsite: Holding Tank, WAC246-272A- El Appeal:Enforcement Timelines
0240 0 Appeal:Departmental Qeterminations
0 Onsite: Contractor Certification Other fu,,.N• r Dn1 54i id 311
Requirements
4
Description of Waiver/Appeal (include justification, additional material may be attached.):
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Applicant Signature: Date: //)/'71/7-3
Revised 8/13/2018
This form may be scanned an available for public view on the Mason County Web site.
Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only) cocain 1•
1. Type of Determination Required: Type of Onsite Waiver (if applicable)
Appeal .Waiver None required , : Class A Class B - Class C
2. Identification of Specific Code/ Standard/ Determination (include date of determination or
latest Code/ Standard revision): WitC 2K6 - Z UL A "0 Z(o (U)
3. Nature f Appeal:
ec�ucZ hori zolkl opara vi vet.'ti dralni'C(d cmt) & Idtry
,fritnio(ctit'on -f o Yh k2 '10 5
4. Hearing Official:
❑ Board of Health 0 Health Officer
O Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board 1E( Environmental Health Manager
5. Mitigating Factors:
— C/teed OY1 40 51.r S tjtl(1 6e. 13 ' 't i bUildali 4044 fi'0/1 ,
— FaUrrda{bra 1, On o Slab /lo 6ase,fric+?ld or caw( pace-- col- is r&l a 'veAy Rolf1
— V(4)or bait"ef WllI 6L tvin(Rce v✓tf.hL Alb 4 fodfi' S Wend above botbmuf 6L.iden,
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: i2------ Date: 1I / fS/77 ?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:
VHealth Official Signature: Date: 11 /172:,
Revised 8/13/2018
0 This form may be scanned and available for public view on the Mason County Web site.
Page 2of2
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