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HomeMy WebLinkAboutWAI2024-00002 - WAI Health Waiver - 1/8/2024 MASON COUNTY COMMUNITY SERVICES euildin%Planning Enviranmemal Heelth,Community Health 415 N 6'Street, Bldg 8, Shelton WA 98584, Shetton: (360)427-9670 ext 400 'lee Belfair: (360)275-4467 ext 400 a Elma: (360)482-5269 ext 400 FAX (360)427-7787 Application for WalvertAppeal Amount Paid: AL ct Receipt Number: L OW TC( Instructions W -c gLOPA —C)LD30a- 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 Nameof Applicant AC,0,3 'rn�c5�A i, +1 LLL Telephone 32 q -I0\ IA6 PIVW vA 1ty, Mailing Address of Applicant (I UM J�UIw qBi S4 city state k/J& zip T3 01 12-digit Tax Parcel No. c1 q fl � — -tL � — —0 a- S2 1 � Site Address \lvq 0 S V C 7e cl l en'� l , 11,,,, Subdivision Name and Lot &-M �iwl'<. 4,,� ��- PART 2: Nature of Waiver/Appeal ❑ Contractor Certification Requirements ❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists) Jill, Separation ❑ Food Sanitation Requirements ❑ Building Pemlil 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 Waive r/Appeal(include justification, additional materialnmay Ibn�e attached.): Applicant Signatur . Date: /. 8•L J:\EH Fotms\Waiver-Appeal Mason County Local Revised 1202017 Page 1.172 J � PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onslte Waiver(if applicable) �c G , ❑Appeal (Waiver ❑ None required ❑ Class A ❑ Class B ❑ Class C ✓V — 2. Identification of Specific Code/Standard/Determination(include date of determination or latest Code/ Standard revision) VV)IrC i f�lb, �}-�--g A_�'\-r ffo 3. Nature of Appel,; (/ l��ri` �LV C��6v(1✓1 V�- IKId 1`S P-,-IRU [XOk IA/7CM .tr. 2 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: J V n-dA 6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has been submitted. 2 Staff Signatur Date: / t zh;iLcj 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: J:\EH Forms\Waiver-Appeal Meson County Local Revised 1202017 Page 2 of