HomeMy WebLinkAboutWAI2023-00117 - WAI Health Waiver - 11/29/2023 MASON COUNTY
COMMUNITY SERVICES
Building Planning Emirmmenbl Hedth,Community Health
415 N 6a Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 4 Beffair: (360)275- 467 ext 400 4 Elma: (360)482-5269 ext 400
FAX (360)427-7787
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Application for Waiver/AppealIOnI� ILIIJI
Amount Paid: NOV 2 9 2023
Receipt Number: BYa_
Instructions3
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 �4 0619dign A)dlet Telephone&0- ZT/-0'V7-
Mailing Address of Applicant 5201 t t11U�+�C NL
city #ja�oixiwrl state S& zlp 98346
12-digit Tax Parcel No. Z ? l 0 - 2. - Q O Q S 2
Site Address Z e [4 V:tetA-) D2 G9'jjYVitW .N.
Subdivision Name and Lot P�hmn iSP. 51wz SG7 4,--5 tdk*8z
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer,Pumper,O&M Specialists)
❑ Separation El 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 Onsite Standards ❑ Departmental Determinations
❑ Other
Description of Waiver/Appeal(include justification,additional material may be attached.):
Founrio inr1 r l WaAt nt -ftnM C.r11-f hnnlL. V'IOOtntl An if rltlr P.
horiv^nknl S rn41nn �Vrom fir *z IAO IP.SS -Vhnn V"S
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'-M1.r.nr yOtaJ 4or �1 r fm.Slr�xn.�foil�.
Applicant Signature: Date: Ilj Z: L67_!5�
J:\EH Fotms\Waiver-Appeal Mason Cowry Local Revised 1/2=017
Page 1 of2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
n Appeal �Iaiver n None required n Class A ❑Class B ❑Class C [D Ctt-
2. Identification of Specific Code/Standard/Deternination (include date of determination or latest Code/
Standard revision)
3. Nature of Appeal: ��� C r ,V`rr,p✓ 1�0 /'^O��lf
1/N(JI 1Yl of
cr
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board
,,AA U Environmental Health Manager
5. Mitigating Mitigating Factors�� K rA DLA 2WCl'FCl/I n-f— l Ot��K /A DLA aWC FG�IA—n-f— l Ol,-
6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted. �/7��
Staff Signature: !— \- l Date:
PART 4: Determination of the Hearing Official
(d"The hearing ofcal has determined that approval of this request will not adversely affect pudic 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 dented.This decision is based on the following findings and conditions:
Hearing Official Signature:_ Date: / L 1 2-
J:TH Forms\Waiva-Appeal Mason County Local
]teviaed 1202017
Page 2 of
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