HomeMy WebLinkAboutWAI2024-00003 - WAI Health Waiver - 1/8/2024 MASON COUNTY
COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health
415 N 6"Street, Bldg 8, Shelton WA 98584.
Shelton:(360)427-9670 ext 400 k Belfairr: (360)2� B5-44677M 400 * Elma: (360)482-5269 etd 400
FAX
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Application for Waiver/Appeal
Amount Paid: P-49��.
Receipt Number. A!4- v.-vv
Instructions Wm' a;L .-00cx)3
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. ApplicandParcelldgntifi tt''lop
Name of Applicant PN� (bym5\Ys L, L Telephone --lox '❑��
Mailing Address of Applicant
city� Nh Js- ``ll State}Ia_ Zip
12-digft Tax Parcel No. )_ q `� 1 — —.S 3 — —L V— J—
Srte Address I (Pza C'/ TV JU6'
Subdivision Name and Lot -
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
10 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 Onsite Standards ❑ Departmental Determinations
❑ Other
Description of Waiver/Appeal(include just��ifica��tion, papdditional material may be attached.):
Applicant Signature: Date.
]:\EH Forms\Waiver-Appeal Mason County Local Revised 120/2017
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PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsde Waiver(if applicable) q
o AppealYVaiver ❑ None required a Class A o Class B o Class C (,llC4-Z-�
2. Identification of Specific Code/Standard/Determination(include date of determination or latest Code/
Standard revision) w&,?
3. Nature of Appeal: hw�[ �VI �1
Q( (P()61 �rti h
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board A Environmental Health Manager
5, Mitigating Factors: e _ 4d &A±QlA QtiC
6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has y�� q,- p�nn been submitted. /
Staff Signature: r e v ' I Date: ` J
PART 4: Determination of the Hearing Official
9' The hearing official has determined that approval of this request will not adversely affect public health and
is hereby gninted.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: a Date: z
1:\EH Forms\Waiver-Appeal Mason County Lncal Revised 1/20/2017
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