HomeMy WebLinkAboutWAI2024-00016 - WAI Health Waiver - 2/4/2024 SON COV W e t a O
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Public Nie, Health
Always working for a safer i healthier Mason County
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 Waiver/Appeal
Amount Paid: I S 4 F E s v ;_
Receipt Number:
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Instructions 1" _--
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 JiM \viti.--CvC1L Telephone 3(40-1S —121—(o
Mailing Address of Applicant - 0, y, (0 2-
City 0,-=4.µis..A- State wA Zip
12-digit Tax Parcel No. 4- `_ 3 -- S d -- 6 d 4- O
Site Address 1 SO 1J.. bt S Co L✓b. 9 d S4-6
Subdivision Name and Lot L.4v—a arc 3 -:e4c.,—r dro
FFB l 4 20
PART 2: Nature of Waiver/Appeal RC F/ 4
❑ Class B Reduction in Vertical Separation ❑ Food Sanitation Requirements VFD
❑ Building Permit Review Policies 0 Group B Water System Regulations
❑ Location,WAC 246-272A-0210 ❑ Water Adequacy Requirements
gHolding Tank WAC 246-272A-0240 ElEnforcement Timelines
Mason County Onsite Standards ❑ Departmental Determinations
❑ Contractor Certification Requirements 0 Other
(Installer,Pumper,O&M Specialists)
Description of Waiver/Appeal(include justification,additional material may be attached.):
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Applicant Signature: Date: 2.--13 Z.4+
J:\EH Forms\Waiver-Appeal Mason County Local Revised 12/1/15
Page 1 of 2
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PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
o Appeal `Waiver ❑ None required o Class A ❑ Class B ❑ Class C Lo 641 —'
2. Identification of Specific Code/Standard/Determination(include date of determination or
latest Code/ Standard revision) q7 i / Zi( Z� �- Z 4 Zt 0
3. Nature of Appeal: 1/V /
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4. Hearing Official:
❑ Board of Health 0 Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board Environmental Health Manager
5. Mitigating Factors: .Pi J I ( `
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: Date: Z((57L1
PART 4: Determination of the Hearing Official
[fit--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: 2//6/1-,6
J:\EH Forms\Waiver-Appeal Mason County Local Revised 12/1/15
Page 2 of 2