HomeMy WebLinkAboutWAI2024-00076 - WAI Health Waiver - 6/28/2024 t
DowSigq Envelope ID:993pA41`3-9E35-43038E06327B45482n34
MASON COUNTY
COMMUNITY SERVICES
Building,Planning•Emironmental Health,Community Health
415 N e Street, Bldg 8, Shelton WA 98684,
Shelton: (360)427-9670 ext 400 •' 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:
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. ApplicantlParcel Identification
NameofApplicant DENNIS PAVLOV Telephone 1-253-737-8667
Mailing Address of Applicant 33036 42ND AVE S
City FEDERAL WAY State WA zip 98001
12-digit Tax Parcel No. 4 2 2 1 6 _ 5 2 _ 0 0 1 4 3
Site Address 61 N TYEE PL HOODSPORT WA 98548
Subdivision Name and Lot LAKE CUSHMAN #12 TR 143
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
V Other
Description of Waiver/Appeal(include justification, additional material may be attached.):
Location of deck footing from existing drainfield legs is a14.09'on the North side,and 4.01'on the East side.
Due to lot size and indsting s!0c,the MH was placed in the only available location.The deck was already
constructed!and we are applying for this waiver 8 pemdt after lye fact.
r �,4 6/28/2024
Applicant Signature:ld` Date:
1:\F31 Forms\Waiver-Appeal Meson County Local Revised 1/202017
Page 1 of2
DOaSign Envelope ID'.99MA4F3-9E3S 303-eEOD-3211y454 W2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver If applicable)
l
❑Appeal q,,Waiver ❑ None required ❑ Class A ❑ Class B ❑Class C LO«-�
2. Identification of Speck Code/Standard/Determination(include date of determination or latest Code/
Standard revision) // , ,,Z nh o.�(a
3. Nature of Appeal: �0 l/ —(W Vn
r01 2 }-m,�4'wt�m.
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board PIC Environmental Health Manager
:td1
5. Mitigating Factorsiq-A f [ n Un!
6. 1 have received this waiverlappeal request. It is complete and mitigation required by the state and
local policy has been submitted.
Staff Signature: - n ` Date: -7 (�Z
PART 4: Determination 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 detemlined 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: 7 L 6 2
1:\EH Forms\Waiver-Appeal Mason County Local Revised 120R017
Page 2 of 2
a p m \
m 0 z z 0 �s
0 p m z -+
rm U � AS.
u0mD z NeyEF
4 � M
; � e op
rn D n O
nNi CO m
Oco
?
A A
w .� cmnm
Ul
1 Dm
my
D
s
W
O m'
O
.8 ,94
Z j
MH o
O _
0 U
n
m
m ,
mm 4. ,
o CD
o � _ 6u4s�x3 '
-------- .OL
N
g N '
82.39'