HomeMy WebLinkAboutWAI Health Waiver - 9/27/2024 MASON COUNTY
COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health
415 N e Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 4 BelfF�360)2 5-44 87xt 400 d• Elma: (360)482-5269 ext 400
Application for Waiver/Appeal
Amount Paid i"I 5' ffyy �
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. Applicant/Parcel Identification
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Name of Applicant k / t � �--
Mailing Address of Applicant 2000
o1^��.�,�,.� State L, )A-- Zip QSS�U
City I'
12-digit Tax Parcel No. `7
Site Address
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Subdivision Name and Lot�s�1k,�ti R•�1 4 �� A?-OYt
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 Crate Standards ❑ Departmental Determinations
f& Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
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Applicant Signature: o. <�� Date: 4 �Z6
1 Macon County Local Revised 1/20/2017
11EH Forms\Waiver-Appeal Page 1 of
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable) Ltivm-
ee
n Appeal Waiver ❑ None required � Class A ❑ Class B ❑ Class C
2. Identification of Specific Code/Standard/Determination�(include date offA determination or latest Code/
Standard revision) Vv�v '6 vI.'�r�i-OZ3-1 o3Y—SL
3. Nature of Appeal� l) M�,I, 5'W- c� oQJrJy,, -1-�y,ch
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board X Public Health Director
❑ Certified Contractor Review Board ❑ Environmental Health Manager
5. Mitigating Factors*. - � yl) _ r O i vta Ia.h� o Z
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- VI fi rt5�t-u-vl-r2_�ot`hP.�S nfo S�v�-d .
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: }'o no.-iv Ssw� Date: 127 (V-1
PART 4: Determination of the Hearing Official
YThe 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 0 Date:
J:TH Forms\Waiver-Appeal Meson Cowry Local Revised 1/20/2017
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