HomeMy WebLinkAboutWAI2024-00072 - WAI Health Waiver - 7/22/2024 MASON COUNTY
COMMUNITY SERVICES
audry Planning Emnroamental Health Comtranhy Health
415 N 6"Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 O Belfair: (360)275-4467 ext 400 4 Elma: (360)482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid:
Receipt Number�tlea �IIrlf� fix S7y ��
Instructions
1. Complete Parts 1 and 2. No determination can be made until these parts hre-YOIIYcomoletetl.
2. Fees maybe billed for waivers and appeals, based on the Environmental Health Fee Zchedu(e.
3. Submit completed application with attachments to Mason County Public Health for review.
PART 1. Applicant/Parcel Identification Name of Applicant Yf'.c-. (7rc.taoT 9 Telephone J(JV - 561- 428 (
Y--nn 1
C-.
Mailing Address of Applicant 20 b7 Y"a•- cy.c-�\ sqi
city C�—k 6 (C— ."(— State W C, zip gd 3(oAo
12-digit Tax Parcel No. —Z Z O —L 17 -- 1� L _ C=) I s
Site Address w'�l•.n� PI_ n lj l,ti� t,.lr•- G.ctx 3by
Subdivision Name and Lot I r nn S tr- �n,�Ges Ik '( ' �I 1 q,Ck- f
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
❑ Separation ❑ Food Sanitation Requirements
❑ Building Penult Review Policies ❑ Group B Water System Regulations
9- Location, WAC 246-272A-0210 ❑ Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Onshe Standards ❑ Departmental Determinations
❑ Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
9L"- 1-o CuU �r . LAr.I--/- 4'�r . /oer J-d
�7cr 'T w� Pr y .4_ 1 -b w/ i 3 ° V S
Applicant Signature: Date: 7" 7 O ' 2 e
J:\EH Fomns\Waiver-Appeal Mason County Local Revised 1202017
Page 1 of 2
i ,
PART 3: Public Health Evaluation (Staff Use Only)
f. Type of Deter/urination Required: Type of Onslte Waiver(if applicable)
❑Appeal �j Waiver c None required F Class A ❑ Class B ❑ Class C LO C�
2. Identification'of Specific Code/Standard/Determination (include date of determination or latest Code/
Standard revision) w 6-Z7?Z-A-o Zi-� 0
3. Nature of Appeal: ��p �
i9.t` NCv 14M AIf.IC a tre�eevc
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board '�,r Environmental Health Manager
5. Mitigating Factors:
- YYltnirn to vn I r � y��crn( Sc�rdl yi°vr
a
4
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: V"�± -I
D � Date: f I?i3&d
PART 4: Determination of the Hearing Official
kw 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: Z- 2
7'1EH Forms\Waiver-Appeal Mason County Local Re wd 1/202017
Page 2 of