HomeMy WebLinkAboutWAI2024-00081 - WAI Health Waiver - 8/23/2024 MASON COUNTY
COMMUNITY SERVICES
Building,Planning,Enviranmental Health,Community Health
415 N 6" Street, Bldg 8, Shelton WA 98584,
Shelton. (360)427-9670 ext 400 Belfair: (360)275A467 ext 400 •:• Elma: (360)482-5269 ext 400
FAX (360)427-7787 IZ
Application for Waiver/A Amount Paid:
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 Sche e.
3. Submit completed application with attachments to Mason County Public Health for revie
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PART 1. Applicant/Parcel Identification 9Fc`c2c���Oj
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Name of Applicant�GC w16Uhl/� �!/G/V.G�- Telephone
Mailing Address of Applicant
City ��✓�� State 44_ Zip li�dYv
12-digit Tax Parcel No. �A,— 2 b -2-
Site Address Zf 2C it`if Cuiau� LAm� C fSGSG Pu r 4o'O `�'
Subdivision Name and Lot S'{46VSGl' '
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 Wail (include justification, additional material may be attached.):
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Applicant Signature. Dater 2
]'/CH Pormsl Waiver-Appeal Mason County Local Rcvlsed 1/20/2017
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PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
i Appeal WWaiver None required c Class A c Class B ❑ Class C
2. Identification of Specific Code/Standard/Determination (include date of determination or latest Code/
Standard revision)
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3. Nature of Appeal.
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4. Hearing Official.
❑ Board of Health ❑ Health Officer
L7f Pollution Control hearing Board q Public Health Director
❑ Certified Contractor Review Board k7A` Environmental Health Manager
5. Mitigating Factors:
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& 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
H).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 TH Forms\WeiveoAppeal Mason County Iswal Revised I/2W2017
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