HomeMy WebLinkAboutWAI2024-00099 - WAI Health Waiver - 10/17/2024 �ASpN.Cna.-
Public®rheaftler HealthAlways working for Mason County
415 N e Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 eKt 400 4 Belfair:(360)275-4467 eKt 400 tr Elma:(36
FAX (360)427-7787 In
Application for Waiver/Appeal Amount Paid: 9.SReceipt Number: 09y0c7
Instructions
1. Complete Parts l and 2.No determination can be made until these parts are fully ceraoleted.
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
Name of Applicant PATRICK MCGILLIVARY Telephone 2064985416
Mailing Address of Applicant PO BOX 130
City LILLIWAUP State WA Zip 98555
12-digit Tax Parcel No. 3 2 4 1 2 __ 1 1 9 0 0 6 1
Site Address 722 SEAGULL WAY, LILLIWAUP, WA 98555
Subdivision Name and Lot 324121190061
PART 2:Nature of Waiver/Appeal
❑ Class B Reduction in Vertical 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
❑ Contractor Certification Requirements ❑ Other
(Installer,Pumper,O&M Specialists)
Description of Waiver/Appeal(include justification,additional material may be attached.):
REDUCED HORIZONTAL SETBACK FROM R/A TO SURFACE WATER(75-100FT)
IF RESERVE AREA IS EVER NEEDED PRE-TREATMENT WOULD BE REQUIRED TO MEET
REDUCED HORIZONTAL SETBACK REQUIREMENTS
Applicant Signature: Date: 10/16/24
JaEH Forms\Waiver-Appal Mayon Co ty L Revised 12I7/IS
Page I of 2
PART 3:3: Public Health Evaluation (Staff Use Only)
I. Type of Determination Required: Type of Onsite Waiver(if applicable)
❑Appeal //` Waiver LiNone required ClClass A ❑ Class B ❑ Class C LDCA71-
2. Identificationof Specific Code/Standard/Determination(include date of determination or
latest Code/Standard revision)
3. Nature of Appeal:
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-4. Hearing Official: !�
❑ Board of Health ❑ Health Officer �Rf'
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board Environmental Health Manager
5. Mitigating Facto s:
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6. I 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
hea0h and is hereby granted. This d1sion is based op 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: b "' 2- 7 y
1:\aH Forms\Waive Appeal Mason County Local Revised 12/1/15
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