HomeMy WebLinkAboutWAI2024-00021 - WAI Health Waiver - 3/11/2024 MASON COUNTY
COMMUNITY SERVICES
auild'vrq Plannim2,Enviranmerrtal Healde Community Health
415 N 6th Street, Bldg 8,Shelton WA 98684,
Shelton: (360) 427-9670 ext 400 2, Betair: (360)275-4467 ext 400 4 Elma: (360)482-5269 exit 400
FAX (360)427-7787
Application for Waiver/Appeal j
Amount Paid: Li _ 1 _
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Receipt Number. vy- 1
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Instructions '
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1. Complete Parts 1 and 2. No determination can be made until these parts are fully completed. ss
2. Fees maybe billed for waivers and appeals, based on the Environmental Health Fee Schedule. V.
3. Submit completed application with attachments to Mason County Public Heath for review.
PART 1. Applicant/Parcel Identification
Name of Applicant \b f 1�r 6 b ar )�� Telephone �6 �' 2Vf- -712
Melling Address of Applicant 47 2f� &C� Ak"--- 5 . -
city State wb- Zip L3 91I 6
12-digit Tax Parcel No. 2— Z 2 a _ s- O _ d C) 6 Z o
Site Address � 7 (-° —rt�r+�u� o-. �1U.."(' `Q�. l t "�4 ✓.1 W .A
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
+ ❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
2� Separation ❑ Food Sanitation Requirements
❑ Building Permit Review Policies ❑ Group B Water System Regulations
❑ Location, WAC 246-272A-0210 ❑ Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Onste Standards ❑ Departmental Determinations
❑ Other
Des c I tion of Weaver/Appeal (include justification, additional material may be attached.):
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Applicant Signature: Date:
1:IEH Fomts\Waiver-Appeal Meson Cosmty Local Revised lf=2017
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PART 3: Public Health Evaluation (Staff Use Only)
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: LW NJ q-�, dw —7 O (cydJ
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board ❑ Environmental Health Manager
5. Mitigating Factors:
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6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted. 1
Staff Signature: (,IJ—LAnl Date: Y_ 2'�
PART 4: Determination of the Hearing Official
,e ]—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:
J-.IIM Forms\Waiver-Appeel Meson County Local Revised t20/2017
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