HomeMy WebLinkAboutWAI2024-00061 - WAI Health Waiver - 7/3/2024 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 -e Belfair: (360)275A467 ext 400 v Elms. (360)482-5269 ext 400
FAX (360)427-7787
Application for W i.� ver/Appeal
Amount Paid �, �q��111l
Receipt Number. l- - NalLIZ
Instructions 1. Complete Parts 1 and 2. No determination can be made until these parts are 2. Fees maybe billed for waivers and appeals, based on [he Environmental Hea
3. Submit completed application with attachments to Mason County Public Health for review.
PART 1. Applicant/Parcel Identification
Name of Applicant �l j/Y'/ 2F�-9s/4 Telephone 350-1 6 3yR�
Mailing Address of Applicant 2wp) Hui eu.y -bl2
City MrgcyoI1Gz //State wA Zip��C�
12-digit Tax Parcel rN'7o. � 2 n2 2 nJ __ -5 L1'--/L � ! ,�
Site Address J r I �� M� I���r7 KE /DPI W,� S%
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.I
TAii4 - is ups T45A4 51 �or)rroari H
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Applicant Signature. �i Lug/� j.!t - J l].97 ` Date- W-.rl _ 2-0 zq
1:AEH Fonmr W giver-Appeal Mason County Local Revised 1l202017
Page 1 M 2
PART 3: Public Health Evaluation (Staff Use Only) LXC f
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
_-. Appeal ri�Waiver None required i Class A Class B Class C
2. Identification of Specific Code/Standard/Determination (include date of determination or latest Code/
Standard revision)
3. Nato r of Appeal:
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4. Hearing Official: e M
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board Environmental Health Manager
5, Mitigating Factors
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6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has/'"�'beeeenn submitted.
Staff Signature ` Date, t f L70
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 teby granted Th s dejysion is ba ed ��nn the foilyywing findin s and conditions
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❑ 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. 7/
J9p11 I o ms`,W oivcr-Appeal Mason Cuunp T.ocal Itcciscd 1/201201
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