HomeMy WebLinkAboutWAI2024-00084 - WAI Health Waiver - 8/26/2024 MASON COUNTY
COMMUNITY SERVICES
Building Planning Environmental Hmlth,Community Health
415 N e Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 ❖ Beffer: (360)275-4467 ext 400 4 Elma: (360)482-5269 ext 400
FAX (360)427-7787 �,o/ra5a nlymi
Application for Waiver/Appeal AUG 2 6 2024 IIIIIIIIIIIIIIII
Amount Paid: -Y� _,-,-;;
Receipt Number BY:_____________
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. SubNt coffi ted appkatbn with atiachmeras to Mason County Puw HmNh for review.
PART 1,.Applican1nttlParcel Identification
Nameof Applicant rr-eeil0ln "✓Ie I-I-(. Telephone RS312 1- 9L5X
Mailing Address of Applicant a-)2` i:a s Ake_ Ave C #3/U
City Sen#(e State 6v _ zip 9fl dZ
,z-dgR Tax Parcel No- 3 I g 0 Z _ S o _ D o t ! 0
Site Address I50 W- Fre IIJ4n Ln7e- , She lfsrt WA 925s`F
Subdivision Name and Lot 24d(-.rlA Pavk kof 11
PART 1: Nature of WaivedAp{wal
❑ Contractor Certification Requirements
FS Class B Reduction in Vemcai (insfaft,Pumper,O&M Speciariscs)
K 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 lGnelines
❑ Mason County Onsite Standards ❑ Departmental Determinations
D Other
Desctiptlon of WslnerfAppea,(InclUde Jvsfmcatton,additional mtst rW may be ettched:):
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Applicant Signature: n-Lit l Mh`wjcr Date: h-7 8 fufi r7f 17+
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79EH Forms\Waiver-Appeal Mason County Local Revised 1/2 012 01 7 Ka(, "0 i74'd� lot
Pag 1of2 �1
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Detee`er///mi�� ❑nation Required: Type of Onsite Waiver(if applicable)
l y /�
❑Appeal )yvaiver ❑ None required ❑ Class A ❑ Class B Class C Vv
2. Identification of Specific Code/Standard/Determination (include date of determination or latest Code/
Standard revision) 1- /' -� rw / _ 2777�-0uT
3. Nature of Appeal: V`r v"W i l V'!
1� +
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4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board li;� Environmental Health Manager
S. Mitigating Factors:
6�VWtllAi,(.g '1`t.-521'lP2
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:
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 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: o z 9 2 r
7:\FH Forms\Waives-Appeal Mason County Local Revised 120/20/7
Page 2 of 2
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