HomeMy WebLinkAboutWAI2024-00107 - WAI Health Waiver - 11/25/2024 MASON COUNTY
COMMUNITY SERVICES
9ugding,Plennln%EnvlrmmeM lHenldLCormnunity Heeler
415 N 6'Street,Bldg 8,Shelton WA 98584,
Shelton: (360)427-9670 ext 400 4- Belfalc(360)276-4467 ext 400 4 Elma:(360)
FAX (360)427-7787 llyfl ll'7�
Application for Waiver/Appeal NOV 2I S 2024
Amount Paid: 95 I� //o B'�p// gy
Receipt Number: Y
Instructions Wo-Z y02q - 601 07
1. Complete Parts land 2.No determination can be made until these parts are Polly will ed.
2. Fees maybe billed for waivers and appeals,based on the Environmental Health Fee Schedule.
3.. Submit completed application_with attachments to Masan County Public Health for review.
PART 1. Applicant/Parcel Identification
Name of Applicant 1�p U -A Asli4�* — Telephone
Mailing Address ofApplicare q30 F- ��r-� '-`�^'k ar
city state LJA zip 01ASA2
12-digit Tax Parcel No. a
.Z -7-- -'L -2� -- -CL LL — 1 Z� Q
Site Address V 1L
Subdivision Name and Lol
PART 2: Nature of WaiverlAppeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer,Pumper,O&M Speclalists)
Cl Separation ❑ Food Sanitation Requirements
❑ Building Permit Review Polloies ❑ Group B Water System Regulations
U Location,WAC 246-272A-0210 ❑ Water Adequacy Requirements
❑ Holding Tank WAD 24B-272A-0240 ❑ Enforcement Timelines
❑ Mason County Onsite Standards ❑ Departmental Determinations
❑ Other
Description of Waiver/Appeal(Include justification,additional material may be attached):
Applicant Signature: Date:_�
l:\EII Fomss\Wniver-App.I Meson C.stty Locel Revised 120I2019
I'ege 1 art
PART 3: Public Health Evaluation(Staff Use Only)
t, Type of Deteru{nmetlon Required: Type of Oneite Waiver(if applicable) ' ^
o Appeal pwa. er ❑None required ❑Class A ❑Class e ❑Class C V"
2. Identification of Specific Code/Standa�DAe-�ten�nination(includ-e�r date of determination or latest Code/
Standard revision) i 1�7�(9 2 ! L,'I —O m
3. Nature of Appeal: ,�. p ems ,.., _.. �1_. l -fyI/y✓�
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:
e. 1 have received this waiverleppeal request. It is complete and mitigation required by the state and
local policy has been submitted.
Staff Signature kltvnf Dale:
PART 4: Determination of the Hearing Official
&-Thehearing
hereby granted.I has This decisioined that Is based on thel of olohwing findings request landtconditonln:affed public health and
❑ 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 folowing findings and conditions:
Hearing Official Signature:
Y- Date: It V A
I:TH Forms\WaiverAppesl Meson County Laml Revised 1202017
Page 2 of2
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OV2024-00136- SIDE SETBACK-5' MIN RR2.5 Zoning
Front Yard Setback.25'.
a9k=mnntne woos. Side&Rear Yard Setbacks. Residential dwelling
SCALE I tt =y01 and accessory structures is 20',
i t OR 10%width of lot if not more than 1 00'wide
r I d 20 3.
vo OR approved ADV
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Disdeimel:Mason Corny doss not recluse a
wrvey to oblaln a bWmlm permit.As a result,silo
plans may rot reflect arcerele data.It ie ma
appliforin;responsiblllly to comply th soffit
mweamsnls.