HomeMy WebLinkAboutWAI2025-00001 - WAI Health Waiver - 1/2/2025 MASON COUNTY
COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health
415 N 6o Street,Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 y Belfai�3( )2 427 77 ext 400 fi Elma: (360)482-5269 ext 400
Application for Waiver/Appeal
Amount Paid: ✓,9N��
Receipt Number:
Instructions UYI2025- 00� RFCFi`F 1�15
0
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 f. Applicant/Parcel Identification
360-701-0075
Name of Applicant Jeff Lovely Telephone
16634 Sargent Rd sw
Mailing Address of Applicant
Rochester State We 98579
Zip
City
3 1 9 0 8 -- 3 1 -- 0 0 02 0
12-digit Tax Parcel No.Site Address 251 SE Norquist Shelton
Subdivision Name and Lot
PART 2: Nature of WaiverlAppeal ❑ 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
❑ Water Adequacy Requirements
❑ Location,WAC 246-272A-0210 ❑ Enforcement Timelines
❑ Holding Tank WAC 246-272A-0240 ❑ Departmental Determinations
O Mason County Onshe Standards ❑ Other
Description of Waiver/Appeal(include iusti ication,additional material may be attached.):
We are installing a new home after a fire destroyed the last one.
The new home is wider than the last one leavin us onl 2ft bin from the septic tank.
We can not move the home the other direction due to a concrete wall.
Applicant Signature: Date: Z"
Revised trzpa017
J:\Ef1 Forms\Waiver-Appeef Masov Couvty local page I of 2
PART 3: Public Health Evaluation (Staff Use Only) WCa
Type of Onsite Waiver(if applicebla
1. Type Determinafion Required: n Class A ❑Class B n Class C
n Appeal x Waiver n None required
2. Identification of Speck Code/Standard/Determination(include date of determination or latest Code/
Standard revision) W46 'AY6 A•0210
3. Nature of Appeal: Anr)en/d 1 +�• -�^� itYrl
e I W 8o rathietm 11?r ri
_ f u
4. Hearing Official: ❑ Health Officer
❑ Board of Health ❑ public Health Director
❑ Pollution Control hearing Board Environmental Health Manager
❑ Certified Contractor Review Board
5. Mitigating Factors: rl f
nlaw-
6. 1 have received this waivertappeal request. It is complete and mitigation required by the stale and
local policy has been submitted.
Date:
Staff Signature:
PART 4: Determination of the Hearing Official
The hearinggranted.l has This decision is based onthel of this request following findingsland conditiionll not s affect public health and
is hereby
❑ 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:
Q / Date: I I I ZOZS
Revised 1/2012017 Page 2 of 2
J:ViH Forms\Waiver-Appeol Mayon Cowty Local
\
\
� {
�
/
& �
�
� 7
�
�
\
a
�% O
�R ¥
!
ram\ ! $4
ƒ £ ic
� taro
ƒ ` f �