The URL can be used to link to this page

Home My WebLink AboutWAI2023-00103 - WAI Health Waiver - 10/17/2023 u, Oo r �, MASON COUNTY COMMUNITY SERVICES Building Planning Emiranmental Helath Community Health 415 N B"Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 L Belfair: (360)275-4467 ext 400 4 Elma: (360)482-5269 ext 400 FAX (360)427-7787 Application for Waiver/Appeal Amount Paid: 0-t 9 Q LS LUJ IS 0 V LS Receipt Number: 13 Instructions �f 1. Complete Pans 1 and 2 No determination can be made until these pans B 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 d U ye I r [� .- K Telephone Mailing �/Address of Applicant 6y0S 15n✓Lc. /y ✓� S. I- - city /YUBUICA! Slate b✓A_ Zip f29, 2. 12-digit Tax Parcel No. O �L - --S-7 1- - o a' 0 1 S Site Address /2 / F. ��/��hC /Q £It n y Zg )n)VS Subdivision Name and Lot )/a ..) 1,)'g =- PART 2: Nature of Waiver/Appeal ❑ Contractor Certification Requirements ❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists) ❑ Separation ❑ Food Sanitation Requirements ❑ Building Permit Review Policies ❑ Group B Water System Regulations M Location,WAC 246-272A-0210 ❑ Water Adequacy Requirements ❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines ❑ Mason County Onsite Standards ❑ Departmental Determinations ❑ Other Description of Waiver/Appeal(include justification, additional material maybe attached.): S�r�r L/tit oAT,o T /o ' ot nR /.v Fi�G Applicant Signature: Date: 0 23 1:\EH Forms\Waiver-Appeal Mason County Local Revised IP10l1017 Page 1 of 2 I J PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver('If applicable) n er '� ��AA/.�� Appeal )"Waiver ❑ None required L Class A ❑ Class B ❑Class C W O1 L/ 2. Identification of Specific Code/Standard/Determination (include date of determination or latest Code/ Standard revision) 3. Nature of Ap(�al�. 4. Hearing Official: ❑ Board of Health ❑ Health Officer ❑ Pollution Control hearing Board ❑ Public Health Director ❑ Certified Contractor Review Board Environmental Health Manager 6. Mitigating Factors act r r v 1 w ' 6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has been submitted. ^^ IV'�-" W' D Y✓ \ Staff Signature: Date: 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: ❑ 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: �1 / Date: /e 17� f:\EH Forms\Waiver-Appeal Meson County Local Revised 1202019 Page 2 of 2 , I i i i I i o � � OQ ai „ . rn m r C b � � nq� z lJ 0 k z � S(000 o <-F a�vNj