HomeMy WebLinkAboutWAI2024-00034 - WAI Health Waiver - 4/10/2024 MASON COUNTY
COMMUNITY SERVICES
Building Planning Eovironme�l H�Ith,Community Heahh
415 N 61°Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 Beffair: (360)275-4467 ext 400 A Elma: (360)482-5269 exl 400
FAX (360)427-7787
Application for Waiver/Appeal
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Amount Paid: lS
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
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Name of Applicant KZfI t Lr/1hER rn15oan Telephone
Mailing Address of Applicant 160 3f0t 5Rt
City onion State we Zip 6)c659a
12-digit Tax Parcel No. 3 — S 0 — 0 q 0 Q.
Site Address (b0 �,' Zr't $-,'.
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, 08.M Specialists)
fd- 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.):
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Applicant Signature: Date: b" 9•Z02y
MEH Forms\Waiver-Appeal Mason County Loral Revised 1120/2017
Page 1 of
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PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onske Waiver(d 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) W ����
Prc-�i�CG- p'ZC7
3. Nature of Appeal:
4. Hearing Official:
❑ Board of Health ❑ Heakh Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board 'Environmental Health Manager
5. Mitigating Factors: to J _WM .lam¢
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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
t�subbmi�tted.
Staff Signature: o 1 l yn Date:
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 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 Of Signature:_ Date:
7:\EH Forms\Waiver-Appeal Mason County Local Revised 1202017
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