HomeMy WebLinkAboutWAI2024-00036 - WAI Health Waiver - 4/23/2024 0- At fl36
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MASON COUNTY
COMMUNITY SERVICES
Building,Planning,Environmental Health Community Health
415 N Bin Street, Bldg 8, Shehon WA 98584,
Shelton: (360)427-9670 ext 400 1- Belfair: (360)275- 467 ext 400 4 Elma:(360) 2-5269 ext 400
FAX (360)427-7787 -
1
Application fort' ::.'Appeal
Amount Paid: t�S- _ APR •k+/(piti
Receipt Number: By —
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 Heatth Fee Schedule.
3. Submit completed application with attachments to Mason County Public Health for review.
PART 1. Applicant/Parcel Identification
Nameof Applicant M1M!,&grj9k, YGE Telephone_
Mailing Address of Applicant 21(0 ST AMG 28\VZ V L N ji\[T+l
city 54rz(mm State //,CA- Zip Te gF&!4
12-digtt Tax Parcel No. 3 Z 7- - -4�- Q - Q Q
Site Address 21/0 E. 5T AAln�� vs 1?(2- X/oam4 �y 77,E , Lr 171(3� r¢
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.):
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Applicant Signature: Date: ZZ 2G21'
7:\EH Fomm\Waiver-Appeal Mason County Local Revised 120/2017
Page 1 of2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onslts Waiver(if applicable) ,q
❑Appeal aiver ❑ None required ❑ Class A ❑ Class B ❑Class C
2. Identification of Specific Code/Standard/Determination(include date of determination or latest Code/
Standard revision)
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3. Nature of Appeal:
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4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board I Environmental Health Manager
5. Mitigating Factors: 1-„ nv�, a� ��� . . I• �
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
M6 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: 2
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1202017
Page 2 of
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i > MIKE AND ANITA Williams Contracting
r y SITE MAP FLORENCE Design - Build - Remodel
www.wcontracting.vet
360-556-9964