HomeMy WebLinkAboutWAI2024-00077 - WAI Health Waiver - 7/29/2024 t,oa_e ac�)aq
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MASON COUNTY
COMMUNITY SERVICES
Buildin4 Planning,Environmental Health,Community Health
1415 N 61°Street, Bldg 8, Shelton WA 98584,
Shelton:(360)427-9670 ext 400 fi Belfair: (360)275-4467 ext 400 fi Elma:(360)482-5269 ex[JR0
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid:
Receipt Number: 31J p�-�� `♦ 9 (�' 4
Instructions \ r� ZIP
12
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1. Complete Parts 1 and 2. No detemlination 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
Name of Applicant -0.ae- ra�`" Telephone 3/00 -7$9 -3607
Mailing Address of Applicant �O �' N ` -✓
City—�btt5li W A State` / C Zip L 8.4-0'7
12-0digit Tax Parcel No. 5 Z �_ -- O _ (_� t7 �O .l
Site Address 1Iy � MD 2K+)1n)S L+NNE LSW6 `�pZ4'�U5'"T I/
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,WAG 246-272A-0210 ❑ Water Adequacy Requirements
❑ Holding Tank WAG 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:
1:\EH Foruo\Waiver-Appeal Mason County Local Revised 1202017
Page 1 ur2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsits Waiver(if applicable)
n Appeal YWaiver E None required <Isss A c Class B n Class C
2. Identification of Specific Code/Standard/Determination (include date of determination or latest Code/
Standard revision)
3. Nature of Appeal: C{�. ,/ l i ,fie
J f
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:
IA
ia/
-erA
6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy hPation
n submitted.
Staff Signature: Date:
PART 4: Determ 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: l./// Date: 3 Z
l:\EH Forms\Waiver-Appeal Mason County local Revised t/20/201]
Page 2 of 2
Granting Waivers from State On-She Sewage System Regulations Chapter 246-272A WAC
Effective Date: July 1,2007 Revised April 2017
On-Site Sewage Systems (Chapter 246-272A WAC)
Re uest r Waiver from State Regulations
Section I.
Name: (1) r, Local Health Department/District (2)
............
Address- A/ 2elk
...........
................................................ .............
..........
Telephone' .............. .....11......................
"§1 .1111.11 ''. 11..................I.......... ...........................- ...............................
grisOrre
Property1dentification: (3) —
................. .......................... ............................... ......................................1................................
.............. ....... .. ......................- ..........
Simon U. 1 (..nple by applicant)
WACNumber: (4) WAC Requirement: (5) slit: (6)
...........................................................................
02
246-272A— St?;*' kr cr JiM Waiver Son
Subsection: wy� U�4r— sto
Justification(mitigation meacisne,to be provided): (7)
............
.............................................
Sgdftp I]L (-mpleled by health office,)
Review Criteria: (8) Mitigation Massacres(in addition to those proposed): (9)
ChIs' vvsfxlv� C10
........... (ten i LstrV
;L. .........................................
Comments/Conditions: (10) W
111.11.1...................................I..............................................................................................................................................
...............................................................11.....................I..".............................................................................................................................................................................................
Type of Waiver (11) *lass [ ]Class B ]Class C—Request DOH review before granting? Yes_ No
Neighbor Notification: (12) Required? Yes_ No f I arnsents,easements,etc.properly needed,are g, fled? Yes No Section IV. (witptered by health officer)
This Request For Waiver From State Regulations has been reviewed according to the provisions of Chapter 246-272A WAC On-Site
Sewage Systems. The review criteria applied,and the mitigation measures proposed and/or requirecl,have been evaluated for their ability
to provide public health correction at least equal to that provided by this Sliapter WAC.
Denied Approved/Granted—Subject to all nts,candithons and requirements
remcmspowdin ectionsIl and III.
Local Health Officer (13) Date:
DOH 337-021 Page 26 of32
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