HomeMy WebLinkAboutWAI2024-00063 - WAI Health Waiver - 7/1/2024 vwf[�
MASON COUNTY
COMMUNITY SERVICES
Building Plarming,Environmental Health,Community Health
415 N 6i"Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 O Belfair: (360) 275-4467 ext 400 L Elma: (360)482-5269 ext 400
FAX (360) 427-7787
Application for Waiver/Appeal p
Amount Paid: Soo /7L4
Receipt Number. �t.4
Instructions Q};,
1. Complete Parts 1 and 2. No determination can be made until these parts are fully comoleted'�
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 �1
Nameof Applicant ITC 5tifs-r•41� Telephone 360
Mailing Address of Applicant P. U, &0>c 8'/f
City 5.111 cr cr 1)11 State W P zip
12-digit Tax Parcel No. J 2 Z 1 cy -- —�c -- G (7 3 y
Site Address 3 S'U " Vt . Mo.e-kz� arc.
Subdivision Name and Lot VO4 2 (/Jk'Iie , 144 >Lk
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
B' 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.).
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Applicant Signature: Date: -7-11-2-
14
J:\RI-1 Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsde Waiver(if applicable)
c Appeal qK Waiver ❑ None required ❑ Class A ❑ Class B ❑ Class C CO
2. Identification of Specific Code/Standard/Determination (include date of determination or latest Code/
Standard revision) .• ` �u 6 �-7 _��
3. Nature of Appeal:
4. Hearing Official:
❑ 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 been submitted.
Staff Signature: na[�ry!1 ov• Date:
PART 4: Determination of the Hearing Official
514-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: 1I4�/ Date:
S:\EH Forms\Waiver-Appml Mason County Local Revised 1202017
Page 2 of 2