HomeMy WebLinkAboutWAI2024-00092 - WAI Health Waiver - 9/30/2024 I
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MASON COUNTY BY:_____________
COMMUNITY SERVICES
Building,Planning,Cmi mmental Health,Community Health
415 N 6'"Street, Bldg 8, Shelton WA 98504,
Shelton: (360)427-9670 ext 400 O Bolfair: (360)275.4467 ext 400 4 Elms: (360)482-526 ext 400 �y
FAX (360)427-7787
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Application for Waiver/Appeal 10
Amount Paid: 295 RFCF71�p
Receipt Number: 0q170
Instructions
1. Complete Parts land 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.
13. Submit completed application with attachments to Mason County Public Health for review.
PART 1. Applicant/Parcel Identification
Name of Applicant e6 ay (��I.lppleV Telepphone
Mailing Address of Applicant / D76eday, ST` 7
City gel-% p� -7 State 0 zip / SLIJp
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12-digit Tax Parcel No. L - L Q2 D- -- I _a -- 1 -4 O V /
Site Address
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
❑ Location,WAC 246-272A-0210 ❑ Water Adequacy Requirements
❑ Holding Tank WAC 246.272A-0240 ❑ Enforcement Timelines
❑ Mason County Christie Standards ❑ Departmental Determinations
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Description of Waiver/Appeal(include justification, additional material may be attached.):
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Applicant Signature: Date: 9',23 201It, -
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J-WH Fonms\Waiver-Appeal Mason County local Reseed M20/2017
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PART 3: Public Health Evaluation (Staff Use Only) loam
1. Type of Delerrrlination Required: Type of Onsite Waiver(if applicable)
❑Appeal V Waiver ❑ Nona 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:
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4, Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board !m Public Health Director
❑ Certified Contractor Review Board ❑ Environmental Health Manager
5. Mitigating Factors:
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6. I have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted.
Staff //t�/y
Staff Signature: 'i'V/ Date: �/ /l/17e7
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 fallowing 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: Data:
SdEH Forms/Waiver-AOPeal Mason County Local Revised If2=17
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