HomeMy WebLinkAboutWAI2024-00059 - WAI Health Waiver - 6/25/2024 JUN 2 5 2024 D
® MASON COUNTY BY
COMMUNITY SERVICES
Building,Planning,Environmental Health Community Health
415 N 6" Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 •? Belfair. (360)275-4467 ext 400 -* Elma: (360)482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid: $190
Receipt Number:
Instructions
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 Darrel Pavlovich Telephone
Mailing Address of Applicant 621 E Country Club Dr E
City Union State WA Zip 98592
12-digit Tax Parcel No. 3 Z1 0 q -- (o C) - O O n Z
Site Address 621 E Country Club Dr E
Subdivision Name and Lot Alderbrook Golf& Country Club
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.):
Reduction in 10' setback to drainfield for new deck.
Existing deck cumently does not meet the 10' setback and home owner would like to -
replace the deck on the same footprint along with extending a new deck 15 X14 to
the west per attached site plan.
Applicant Signature: Date' 06.24.2024
Esc- - - '�— —
1:1BH Forms\Waiver-Appcal Mason Count-Local Revised 1/20/2017
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PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
u Appeal Waiver ❑ None required o Class A ❑ Class B ❑ Class C LJ�
2. Identification of Specific Code/Standard/Determination(include date of determination or latest Code/
Standard revision) v4ft- b --1;77'7-At-01"D
3. Nature of Appeal.. 1 "trs
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4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board X Environmental Health Manager
5. Mitigating Factors:
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9
6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted.
Staff Signature: Date:
PART 4: Determination of the Hearing Official
lilf—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:
1:\EH Fonns\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of 2
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