HomeMy WebLinkAboutWAI2024-00018 - WAI Health Waiver - 3/4/2024 MASON COUNTY qR°4 2024
"" 'f COMMUNITY SERVICES REcE/1,F0
' Building,Planning,Environmental Health,Community Health
415 N 6"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 -ve;Ap al
Amount Paid: 7`(9
Receipt Number: l►C , -9 C
Instructions \�, k-10��, OG \
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1. Complete Parts 1 and v2_vNo determination can be made untilese 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 S^--- r i--,24.,\_e_ct-<„__I Telephone 3 4°0 ' -(. c , q - ," V
Mailing Address of Applicant S f Q�. -- v 7"A v-) p p !A b-c__G• cA-., f2 c/f
City 52.A. 6.�p State 4' Zip q'S -iN,
12-digit Tax Parcel No. L O` d L - 2.3 - v / Q
Site Address 57 P "/ -\/' w o o ,-J /P----'(
Subdivision Name and Lot
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 T, Group B Water System Regulations
❑ Location,WAC 246-272A-0210 0 Water Adequacy Requirements
El Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
❑ Mason County Onsite Standards 0 Departmental Determinations
❑ Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
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Applicant Signature:Ste,,", C Date: 9 1
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J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017 Mil
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PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
Appeal 4 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)
3. Nature of Appeal:
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4. Hearing Official:
❑ Board of Health 0 Health Officer
❑ Pollution Control hearing Board fif Public Health Director
O Certified Contractor Review Board 0 Environmental Health Manager
5. Mitigating Factors:
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: 3 7xyzaci
PART 4: Determination of the Hearing Official
.)-1 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:
El 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:
i Date: 375/Z
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
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