HomeMy WebLinkAboutWAI2024-00058 - WAI Health Waiver - 10/21/2024 MASON COUNTY
COMMUNITY SERVICES
Building,Planning Environmental Health Community Health
415 N 6'"Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 % Belfair: (360)275-4467 ext 400 0 Elms: (360)482-5269 ext 400
FAX (360)427-7787 COW
Application for Waiver/Appeal I�J��CO V �D
Amount Paid: (✓ .'�1 �unu` OCT 2024
Receipt Number: Z - 041
Instructions BY
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 Ident' tion
Name of Applicant �Or'l� �frh 45
Telephone . o
Mailing Address of Applicant .S
City �AA -- State ! Zip
12-digit Tax Parcel No. 7�� ZR � L a c1 9
Site Address
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
D scrip ion of Waiver/ //peal(include'ustification, additional material may b attach d.): 1
4h C Off/ tA— d/C /T1 n '/ d �lhl
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Applicant Signatu Date:
!:\EH Farms\Waiver-Appeal Mason County Lq al Revised 1/20�,2017
Page 1 of2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable) /�
❑Appeal r$Waiver ❑ None required ❑ Class A ❑ Class B ❑ Class C w c*�
2. Identification of Specific Code/Standard/Determination (include date of determination or latest Code/
W �+(
Standard revision) • 1I!`C /--MA- Oa(o
3. Nature of Appea: �A-.�^ r`
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4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board NA Environmental Health Manager
5. Mitigating Factors:
pC-S�rV'� V�c7#� UD �l l`l�l'CI�FI' 0'F
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: :�1' WV`� `'��i " ` Date:
PART 4: Determination of the Hearing Official
It 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: ' 4 / Date: r 6 AtIll,
I:\EH Forms\Waiver-Appeal Mason Cowry Local Revised 1/202017
Page 2 of