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Home My WebLink AboutWAI2024-00100 - WAI Health Waiver - 10/17/2024 MASON COUNTY COMMUNITY SERVICES Mucking.Plsnnin%Environmental Health Community Health 415 N 6a Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 4- Belfair: (360)275-4467 ext 400 4 Elms: ( Am 482-Kfig FAX (360)427-7787 10MCME01 Application for Waiver/Appeal Amount Paid: /951— OCT 024 Receipt Number: DNyq Instructions (JAI Zol,l - otaIGOV 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 Identification Nameof Applicant fV/t'W#-- Ir,INf lr`- Telephone y2.��260 - �Y� 9 Mailing Address of Applicant ��//) IA/ T UA/IK7 �i✓lQcc/ city /SS" //wA- State_lz � Zip 91'U 27 12-digit Tax Parcel No. L 2 -2 -- 1L -- CL / Site Address [ 0 Al Ica/ [.� �'DQ QS/�D��T6 �5y671� Subdivision Name and Lot p/UI U or7 2- 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 1111 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 Waiver/Appeal(include justification, additional material may be attached.): v +0 2r4. Applicant Signatur 4K4Date: 7 Z 1:\EH Forma\Waiver-Appeal Macon County Local Revised V20/2017 Page I of 2 PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) , ❑Appeal gyvaiver ❑ None required ❑ Class A ❑ Class B ❑ Class C L r,�._L-C) C ` 2. Identification of Specific Code/Standard/Determination(include date of determination or latest Code/ Standard revision) ��•Ll.�f,Z-�Z/�-,—Q-Z( f� 3. Nature of Appeal: C 1 ^ IV Y t 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: �✓A�fIL(cl .� I O��'� J � 6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has been �su4bmiitt1Med..//�(/�/�/� 1. Staff Signature: D r ' 1 Date: PART 4: Determination of the Hearing Official �- 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: /y 1 1:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017 Page 2 of 2 Ct - - - - - i le-- z --� u o * DELk VIi y 2cl i yu' i & of i o l — — N �� cusp ► rnl 0 b i 00— — — — 9 Y►CL D r cL FIF 60 rj � 10