HomeMy WebLinkAboutWAI2024-00007 - WAI Health Waiver - 1/26/2024 •
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PO Box 1666,415 N 6th Street, Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 4* Belfair:(360)275-4467 ext 400 + Elma:(360)482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid: L9_d Receipt Number
WAI /24 - 0000
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 Identification
Name of Applicant �-- I`��-'� Telephone 2�
Mailing Address of Applicant (.0 / / ) -
City S6,'i ))�-- State G'Jr, Zip Cic3) 15
12-digit Tax Parcel No.
Site Address J7 I
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
❑ Class B Reduction in Vertical Separation ❑ Food Sanitation Requirements
❑ ,Bliilding Permit Review Policies 0 Group B Water System Regulations
p' Location,WAC 246-272A-0210 0 Water Adequacy Requirements
❑ Holding Tank WAC 246-2?2A-0240 ❑ Enfbrcement Tlmetines
❑ Mason County Onsite Standards ❑ Departmental Determinations
❑ Contractor Certification Requirements ❑ Other
(Installer,Pumper,O&M Specialists)
Description of Waiver/Appeal(include justification,additional material may be attached.):
D C t2- - ""1 (\.a �
Applicant Signature: Date: ,/4-3 J
Revised 1/22/2015
This form may be scanned and available for public view on the Meson County Web site.
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PART 3: Public Health Evaluation (Staff Use Only) L0001
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)
3. Nature of Appeal: ,
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4. Hearing Official:
O Board of Health 0 Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board 1;4f Environmental Health Manager
5. Mitigatin• Factors:
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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: I/ 7079r
PART 4: Determination of the Hearing Official
A'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: Z /� L
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20,2017
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