HomeMy WebLinkAboutWAI2023-00101 - WAI Health Waiver - 10/13/2023 MASON COUNTY
COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health
415 N 61°Street, Bldg 8, Shelton WA 98564,
Shelton: (360)427-9670 ext 400 -C Belf3(0 )2 42�787xt 400 6 Elma: (360)482-5269 ext 400
FAX
Application for Waiver/Appeal
Amount Paid:
Receipt Number:
Instructions VJ(>\ )L-D)-3 'v�\ u \
1. Complete Parts 1 and 2. No determination can be made until these parts are fully completed.
2. Fees maybe 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 II�nQkA MUKrtrt•4 'I_ Telephone ` 1V- 702 L'— 7L Z
Mailing Address of Applicant Tb
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City 7 ?? — Gu�
12-digit Tax Parcel No. Aa a s2 2 2 -- 1 L "" O
Site Address // /Uc Ub,yd R11 Or t&A,y Ir G✓A
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 ❑ Group B Water System Regulations
• Location,WAC 248-272A-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 may be attached):
ano 61 ib
L a A
Applicant Signature: Date: �G
Revised 1/20/2017
J:\EH Forms\Waiver-Appeal Mason County local Page I of 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable) _
Appeal aiver ❑ None required ❑ IW Class A ❑Class B ❑ Class C CA-�—
2. Identification of Specific Code/Standard/Determination(include dale of determination or latest Code/
Standard revision) vV4-j ii/ , Z��A�Z�
3. Nature of Appeal: n , A� v 2/'A( � \
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4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board -01 Environmental Health Manager
5. Mitigating Factors: 'D!-puLF.r v°LG� nU-r-- //n���� -
o .. t N u-�-r"Y'
6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted. f �j
Rj-Staff Signature.
tV � Date:
PART 4: Determination of the Hearing Official
�l. 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:
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1 Rcviacd 1/20/2017
JAEH Forms\Waivcr-Appeel Mason County Local Page 2 of 2
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