HomeMy WebLinkAboutWAI2024-00069 - WAI Health Waiver - 7/17/2024 MASON COUNTY
COMMUNITY SERVICES
Building,Planning Environmental Health Community Health
415 N 6t" Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 -e Belfair: (360)275-4467 ext 400 L• Elms: (360)482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid: , jqs.ee
Receipt Number: .l t{- 2aeci
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
Name of Applicant �JnmE Telephone 2S3-31S-4'JC19
Mailing Address of Applicant 2.5514 • -Zbe;:S A,,m S E
City Co V 1 N GToN State \t4A Zip %t7y-2-.
12-digit Tax Parcel No. LA Z 2- 6 -- S O - b O Q O g
Site Address [90 K GL.Ewweoa DR\yE VAODOSpoRTr WA Q9iS4S
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 t
■ Location,WAC 246-272A-0210 ❑ Water Adequacy Requirements I"'777bbb(a---
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Onsile Standards ❑ Departmental Determinations I�
❑ Other �, C
t Description of Waiver/Appeal(include justification, additional material may be attached.): i ci
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t2E0V C£ S1=` 'BACK '�i'2oM `�\/ 'PoRT' �DtS\nI FxS T7� 1ztSE2y£ 1
T)9AiQ F1E�'a t)OW1.1 To A- 5 FEET_ AREA 1S FLAT. t C-
Applicant Signature: vilDate: Gi-2oZ4
J:\EH Forms\Waiver-Appcal Mason County Local Revised 120/2017
Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
❑Appeal q(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) wj�z,v -n2A-orto
3. Nature of Appeal: f0c
(Xr: A .Ovt' w o n-.a va v.-ete_t_o�e
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: J
� c
6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submiitt.e-,dam,, , ^,, .Q
Staff Signature: Ids` `gk `r Date: ?i
PART 4: Determination of the Hearing Official
1. 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: 9i Z
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of 2
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