HomeMy WebLinkAboutWAI2024-00108 - WAI Health Waiver - 12/4/2024 wct-t aoaa C. - cot
MASON COUNTY
COMMUNITY SERVICES
Building Pbnnin0,Environmental Health Community Health
415 N 6''Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 O Belfair: (360)275-4467 ext 400 O Elma: (360)482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid: PJ5
Recelpt Number: [Q4 _4Ct(Qa
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
Name of Applicant Jame6 ENes Telephone (509)432-1173
Mailing Address of Applicant 6812 Lake Paloma Trl
City Spring State. TX Zip 77389
12-digit Tax Parcel No. 3 2 0 0 3 _ 0 0 _ 0 2 0 0 0
Site Address 71 E Sandpiper Ln, Shelton WA 98584
Subdivision Name and Lot Bayshors, Lot#8
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, 08M 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
AK Other
Description of Waiver/Appeal(include justification, additional material may be attached.):
New foundation is under the minimum 5 foot setback requirement(it is in the same place as
—It 1e prr"x s ring home) but we wl r'If emain greater to eet rpm a setbac .
Applicant Signature: %ns� Date: 12/4/2024
7:\EB Soma\Waiver.Appeal Maeoo yLocal Revised 1/202017
Page 1 of
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
❑Appeal aiver ❑ None required ❑ Class A ❑Class B ❑Class Ct---
2. Iderdlfioatlon of Specific Code/Standard/Determination(include date of determination or latest Code/
Standard revision) W t �(o-�� .7 L. .�
3. Nature of Appeal: Tv
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4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board Environmental Health Manager
5. Mitigating Factors:
no }- oP r l ott—
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6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been
f submitted.
Staff Signature:kint" Date: LI IZ'I
PART 4: Determination of the Hearing Official
iz� 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: iz Date: / t , d _
1:\EH Forms Waiver-Appeal Mason County Local Revised 1/2 012 01 7
Page 2 of
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