HomeMy WebLinkAboutWAI2024-00070 - WAI Health Waiver - 7/17/2024 MASON COUNTY
COMMUNITY SERVICES
Building Plarnin Bwironme xal Health,Community Heald\
415 N 61"Street, Bldg 8, Shelton WA 98584.
Shelton: (360)427-9670 ext 400 4 Belfair:(360)275-4467 and 400 4 Elma:(360)482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid: I Q '00
Receipt Number:0—m--laC1CI
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. ApplicanVParcel Identification
Name of Applicant M014 �'i�l( Telephone 53-357 41'17 .
Mailing Address of Applicant 100,97 < T�M.. 0 o.•e
City !_c..kzL- gpj StateZJZIP 10�94 i
t p
12-dlga Tax Parcel No. .3 2 .2 2 6 - 3 S' - O o 0/� O ,fO i _ I
Site Address L.7 y� XE N r-A SLry- Rd & tf1 ir, (A)A
Subdivision Name and Lot t
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 Onstte Standards ❑ Departmental Determinations
❑ Other
Description of Waiver/Appeal(include justification,additional m/at1enal mpay b/re,attached.):'1
52TbGc.lc +rn.r. 'I'{'L
L �s
Applicant Signature: Date: /�, 2 y
J:\EH Foma\Waiver-Appeal Mason County Local Revised 1/202017
Page J of2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onshe Waiver(if applicable) LD N 1 L Appeal Ily w(� aiver � None required ❑ Class A n Class B c Class C
2. Identification of Specific Codel Standard/Determination(include date of determination ar latest Code/
Standard revision) IN
777A,_Ou 0
3. Nature of Appeal: vV � �1�/J"�
r r
4. Hearing Official:
Cl Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board )X' Environmental Health Manager
5. Mitigating Factors
VIA n4,,-J VP,S e t lc7C U�p ��Cf 1)—II I wrn�w
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: Date: I f I 7i
PART 4: Determination of the Hearing Official
lid The hearing offhd 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: 7 2 �/
MEn Forms\Waiver-Appeal Mason Cowry Local Revised 1/202017
Pag.2 of 2
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