HomeMy WebLinkAboutWAI2024-00089 - WAI Health Waiver - 9/20/2024 40) loll Zo2� - o0o8q
MASON COUNTY
COMMUNITY SERVICES
Budding Planning,Environmental Hmlth,Community HmM
415 N 61°Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 G Better (360)275-4467 ext 400 4 Elms: (360)482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid: I I f !� `
Receipt Number: Zo Zy " 07 �0J
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. Applicant/Parc
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'Identiification s8
Nameof Applicant w.5" t"1t V Telephone fig
Mailing
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City Arty/ K) 2State CA /�Zip '�`:351O
12-digit Tax Parcel No. .l — Q,—,1 sQ—�,� QA��
Site Address C '51 '1 �J ��• / v�1'/•n�i W A—.
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
21, 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 Signature: Date: 9 20
1:\EH Fomrs\Waiver-Appel Mason County Local Revised 1/20/2017
Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsde Waiver(if applicable)
❑Appeal Waiver ❑ None required ❑ Class A ❑ Class B ❑ Class C
1 Identification of Specific Code/Standard/Determination(include sate of determination or latest Code/
Standard revision) W n,7.t-(6.Z-7ZA—OZt-r�i
3. Nature of Appea�l�:pp '^ �� .--� �_11 � I�
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4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board Ix Environmental Health Manager
5. Mitigating Factors:
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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 sublmiittteed.� � � ,�rv��
Staff Signature: Y� Y\Q- A�I;r"' ' Date: a Z
PART 4: Determination of the Hearing Official
Mk 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: 7 2-f 2�!
1:\EH Fonns\Waiver-Appeal Meson County Local Revised 1/202017
Page 2 of 2
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