HomeMy WebLinkAboutWAI2024-00058 - WAI Health Waiver - 7/18/2024 415 N.a STREET,SHELTON WA 98584
MASON COUNTY SHELTON:360427-9670,ext 400
COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400
ELMA:360-482-5269,ext.400
'� enans w„mnsrna,m,nenuirk,m,.canm„in a�+iu FAX:360-427-7798
Application, for Waiver or Appeal
Amount Paid: l Receipt Number: 24 — 31A i
WAI 2024 C)4 J S6
Instructions:
1. Complete Parts 1 and 2. No determination can be made until these parts are fully completed.
2. Fees maybe 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 Information
Name of Applicant BAYSHORE CONSTRUCTION Telephone 360-866-9200
Mailing Address 2103 HARRISON AVE STE 2774
city OLYMPIA State WA Zip 98502 Parcel No. 4 'L " - I -L. _ 5 v _ t 1 O O 4
Site Address 24314 N. HIGHWAY 101 HOODSPORT, WA
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
q Class B Reduce Vertical Separation ❑ Food Sanitation Requirements
LJ Building Permit Review Policies ❑ Group B Water System Regulations
❑ Location,WAC 246-272A-0210 ❑ Water Adequacy
Require D
❑ Holding Tank WAC 246-272A-0240 Enforcement Timelines
❑ Mason County Onsite Standards ❑ Departmental Determinate
❑ Contractor Certification Requirements ❑ Other JUL I82024
(Installer, Pumper, O&M Specialists)
Description of Waiver/Appeal(include justification, additional material may be attached.): By
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Applicant Signature:
Revised 82112017
This form may be scanned and available for public view on the Mason County Web site.
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PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite waiver(if applicable) per,
❑Appeal l Waiver ❑ None required n Class A L Class B � Class C t.0 'A' t V
2. Identification of Specific Code/Standard/Determination (include date of determination or latest Code/
Standard revision) vf15vv t f -7777A- 8"2( 0
3. Nature of Appeal: 1D 1 � m f 11
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board �Pe_ Environmental Health Manager ,,
5. Mitigating Factors: �p VsI yl 't'o- AT-"
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on
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
A 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 Forms\Waiver-Appcal Mason County Local Revised 1/20/2017
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