HomeMy WebLinkAboutWAI2024-00034 - WAI Health Waiver - 4/9/2024 MASON COUNTY
COMMUNITY SERVICES
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415 N 6° Street, Bldg 8,Shelton WA 965a4,
Shelton:(360)427-9670 eA 400 + Beifair.(360)275-4467 end 400 4% Elms: (360)482-5269 W 400
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid: to I R,5`
Receipt Number: 1.
Instructions
1. Complete Parts 1 end 2. No determination can be made until these parts are fully completed.
2. Feea may ba billed for waivers and appeals, based on the Environmental Health Fee Schedule.
3. Sutanit colnPletad aPPlication with attachments to Mason County Public Health for review.
PART 1. Applicant/Parcel Identification
Name of Appricant 9en 4• �;11✓764t Folsom Telephone
Mailing Address of Applicant 160 Ec 3.A et
City Union State Wet Zlp �1$59d
12-digit TeX Parcel No. S J— -1 —1 — 5 0 — O q Q Q 6
Ske Address )I,O /?-- 71-1
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer,Pumper, O&M Specialists)
0- Separation ❑ Food Sanitation Requirements
❑ Building Permit Review Policies ❑ Group B Water System Regulations
❑ Location,WAG 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: _ _,��/a� Data: y. 9.wzy
1:MH Fotmt,Wai m-Appeal MewnlCounly Loaf R.AW 1202017
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PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Orate Waiver If applicable) r
❑Appeal �,Wwver o Now required o Class A. o Class B o Class C ✓') �-
2. Identitcatlon of Specific Code/Standard/Determination(include date of determination or latest Code/
Standard revision) � ^ , ,n 07-`I)
3. Nature of Appeal: !/"W
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board 'f Environmental Health Manager
5. Mitigating Factors:
B, 1 have received this waivedappeal 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:
J:1RFiforw\Wiam-Appeal Mason County hied Reviaad MUM
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