HomeMy WebLinkAboutWAI2024-00088 - WAI Health Waiver - 9/4/2024 c
MASON COUNTY
COMMUNITY SERVICES
Building Planning:Environmental Health,Community Health
415 N Sin Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 •- BelfFfAr FAX (360)2 5-4 48677xt 400 'r Elma: (360)482-5269 ext 400
Application for Waiver/Appeal
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Amount Paid: $�� -
Receipt Number: gU -
Instructions
1. Complete Parts 1 and 2. No determination can be made until these parts are fully completed.
2. Fees maybe 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 n ✓ rsl Telephone 4zS
Mailing Address of Applicant Z�n r���t----
City
Cfjfo l-f-nyl State Zip S
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12-digit Tax Parcel No. LaL
Site Address Z_Y 0 F,_
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 Onsite Standards ❑ Departmental Determinations
❑ Other
Description of Waiver/Appeal(include justification,additional material may be attached.):
C
/7t Ohre' R; Date:T I� '
Applicant Signatu e:
Revised UM2017
7:\EH Forms\Waiver-Appeal Masan County Local page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable) (o Cflrz—
❑Appeal *aiver n None required ❑ Class A ❑ Class 8 ❑ Class C
2. Identification of Specific Code/Standard/Determination(include date of determination or latest Code/
Standard revision) vj.p -Z G Z'�A p2( C
3. Nature of e �,� 101
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4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board iR' Environmental Health Manager
5. Mitigating Factors:Qj[,SrrVve. .� Owu/Y�
Lys LT✓1 (� r1wY 1 -F Gm•1-� .
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:
i^�e nF� Date: �2y
,PART 4: Determination of the Hearing Official
2t 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:_ a�� — Date:
1:\EH Form,\Wawa-Appeal Mason County Local Revised 1/20'2017
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