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HomeMy WebLinkAboutWAI2024-00061 - WAI Health Waiver - 7/3/2024 (2) �QMASON COUNTY COMMUNITY SERVICES x�) Building,Planning,Environmental Health,Community Health 415 N 6'a Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 0 Belfair. (360)2754467 ext 400 +e Elma: (360)482-5269 ext 400 FAX (360)427-7787 Application for Waiver/Appeal Amount Receipt Number: Q ,T, %S= InstructionsV.1 1. Complete Parts 1 and 2. No detemnnation can be made until these parts are fully2. Fees maybe billed for waivers and appeals, based on the Environmental Health 3. Submit completed application with attachments to Mason County Public Health for review. PART t. Applicant/Parcel Identification Name of Applicant /- OCA),1-'h`/ Pp-X.S4 Telephone360-606 34R% Mailing Address of Applicant l00 Hw gr=i y yz. city U4N <�0()VC- Z State Zip 1 12-digit Tax Parcel No. I- 2 2 3- 3 - -5 L Site Address 15 r100 e M1r;,0l`l4,4XC- �GL N EST 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 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.): j7AE -r4oy 61 ,Fk Jy -rH-1= or�rraAn�t/ T r Applicant Signature: Date: ILL-17 Z . 20ZY ]:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017 Pagel of2 PART 3: Public Health Evaluation (Staff Use Only) (XG, 1. Type of Determination Required: Type of Onslte 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. Na[ur of Appeal: V t `mo- A rP 44/ em '1 4 G frD 4. Hearing Official: (CSY f41a) z . ❑ Board of Health ❑ Health Officer ❑ Pollution Control hearing Board ❑ Public Health Director ❑ Certified Contractor Review Board Ip Environmental Health Manager 5. Mitigating Factors: rAn aEQ SPgI t zo IT f*1 0 & 1 have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has been submitted. /4 Staff Signature: ` ✓f' Date: ( [ 17 PART 4: Determination of the Hearing Official {„The hearing official has determined that approval of this request will not adversely affect public health and is q%c b ranted. Th s de ion is b ed the foils win findin s and conditions : o v9k s �c rw r s��oti ❑ 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: 1 Date: �f ZoZ� J:\EH Forms\Waiver-Appeal Mmon County Local Revised rnorzdn Page 2 of2 S 1 1 I t 4J 8 1 � I i I 1 I LAK k 1 i i JUL 0 91014 ' 'I .1 j � RECF�IVED -i� I i I A _ , , ! I --A- . [ L ' 1 a_ _L 1 ij I '