HomeMy WebLinkAboutwai2024-00102 - WAI Health Waiver - 10/25/2024 *�oN copry�
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akayr wawno tors heatthler Mason County RFcF 10e
415 N 6'Street,Bldg 8,Shelton WA 98584, �
Shelton:(360)427-9670 est 400 0 Belfair:(360)275-4467 est 400 9 Elma:(360)482-5269 est 400
FAX (360)427-7787 MOW
Application for Waiver/Appeal Amount Paid:Receipt Number:Instructions Uwz Z02q - ooloz
I. 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 Schedule.
3. Submit completed application with attachments to Mason County Public Health for review.
PART 1.Appheant/Parcel Identification
Name of Applicant HOUSE BROTHERS Telephone 3604701707
Mailing Address of Applicant PO BOX 1820
city MCCLEARY State WA Zip 98557
12-digit Tax Parcel No. 3 2 0 2 9 -- 5 1 -- 0 3 0 0 6
Site Address XX SE RIDGE RD
Subdivision Name and Lot MILL CREEK TRACTS BLK 3 LOT 6
PART 2: Nature of Waiver/Appeal
❑ Class B Reduction in Vertical Separation ❑ Food Sanitation Requirements
❑ Building Permit Review Policies ❑ Group B Water System Regulations
0 Location,WAC 246-272A-02I0 ❑ Water Adequacy Requirements
❑ Holding Took WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Onsite Standards ❑ Departmental Determinations
❑ Contractor Certification Requirements ❑ Other
(Installer,Pamper,O&M Specialists)
Description of Waiver/Appeal(include justification,additional material may be attached.):
REDUCED HORIZONTAL SETBACK FROM DRAINFIELD AND R/A TO NEIGHBORING WELL
DMINFIELD AND WA MEET TREATMENT LEVEL A
NEIGHBORING HOMEOWNER NAB BEEN NOTIFIED
Applicant Signature: Date: 10/22/24
J:\BH Forma\Waiver-Appeal Mason Co ty 1. Revised 12/1/15
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PART 3: Public Health Evaluation (Staff Use Only) t 0 e41 (,t 411VW
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
❑ Appeal Y Waiver ❑ None required ❑ Class A ❑ Class B ❑ Class C
2. Identification of Specific Code/Standard/Determination(include date of determination or
latest Code/Standard revision) W*t 2t(6 -If74-010Of)
3. Nature ofAppeal:
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4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board Environmeatal Health Manager
5. N iti ating Factors:
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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. I c�
Staff Signature: / Date: 10 O 41
PART 4: Determination of the Hearing Official
Er 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: LD ,1 Zy
J:\EH Forms\Waiver-Appeal Mason County Local Revised 17/l/I5
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