HomeMy WebLinkAboutWAI2024-00078 - WAI Health Waiver MASON COUNTY
1,
COMMUNITY SERVICES
Building,Planning,Environmental Health.Community Health
415 N 61h Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 : Belfair: (360)275-4467 ext 400 v% Elma: (360) 482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid: It �%_Receipt Number:�'d4 .03L1-��y
Instructions WKy_ aCQy,DOCRC2
1. Complete Parts i 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 Identificcattiioenn� �7/)G, p p
Name of Applicant,�u�� z� Telephone 2 r"�N—9y/— ' /V Z
Mailing Address of Applicant I !ilk� I h o n Ave-R '6L'a •City ��yU- �a State rw4- Zip 150o
12-digit Tax Parcel No. Z 0 S -- V 2- -- _0 0 0 II II ''7^1
Site Address f U 51- ��Nx lT,
Subdivision Name and Lot 5✓J S�./ r
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PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, 08M Specialists)
❑ Separation ❑ Food Sanitation Requirements
❑ Building Permit Review Policies Cl 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 Signat Date:
1:(EH Forms\Waiver-Appeal Mason County Loeal Revised 1/202017
Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only)
f. Type of Determination Required: Type of Onsite Waiver(if applicable) L� !'A L�..t
� Appeal of 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)
3. Nature of Appeal: rG
/rIn-u,rn.�
4. Hearing Official: rtb�
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board � Environmental Health Manager
5. Mitigating Factors: ,.,,,„n .�-r✓ , f !AK _llcft7--
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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
submitted.
�I'Staff Signature: Date:
PART 4: Determination of the Hearing Official
(IThe 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: UZ Date:
J1EH Forms\Waiver-Appeal Mason County Local Revised 120/2017
Page 2 of 2
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