HomeMy WebLinkAboutWAI2024-00030 - WAI Health Waiver - 4/3/2024 �V'
MASON COUNTY
COMMUNITY SERVICES
euicing,Plennii Emdronmentale.hiu Community Health
415 N 6"Street,Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 fi Belfair:(360)275-4467 ext 400 4 Elma:(360)4825269 ext 400
FAX (360)427-7787
Application for Waiver/�ppeal
Amount Paid: (T1�1
ReceiptNumber:
Instructions i
1. Complete Parts 1 and 2.No detennlnatlon can be made until these pens ere fully completed.
2. Fees maybe billed for walvers and appeals,based on the Environmental Health Fee Schedule.
3. Submit completed applka8on with attachments to Mason County Public Heafth for review.
PART 1. Applicant/Parcel Identification
Nameof Applicant4tbV)IMfY1SIDY\CbY1OYUIt101fplephone 3UO -151q -8O-75
Mailing Address of Applicant -115 1A+V1 F1VP CW Slllytt C5
City 11AMVV(Ai-tY State WIR Zip o10r5ol
12-dig8 Tax Parcel No. 2 2 - 3r - -a- g
Site Address sit F g"nrrimf Ln SVICl Yon N1W 9'b(;1b4
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
O Building Permit Review Policies ❑ Group B Water System Regulators
ta 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 Signaturs-1—M e at/ C Date: q 3 ZOZ-
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JAEH Fome\Waiver-Appeal Meson County Local Revised 1/2012017
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PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable) r ,,
❑Appeal alter ❑None required ❑Class A ❑Class B ❑Class C `oc/ (_-
2. Identifcalio of Specific Code/Standard/Determination(Include date of determination or latest Code/
Standard revision)
3. Nature of Appeal, I�GM`/"`M rvtb�lu� �F."1YJ ram[ - ' i�Mil
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4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board Environmental Health Manager
S. Mitigating Facbrs: 1
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6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and I'
local policy has been submitted.
Staff Signature: 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 Official Signature: 1// Date: /f��4-`
1:TH Fomp\Waiver.Appeal Meson County Local aovu d ln(W2017
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