HomeMy WebLinkAboutWAI2025-00009 - WAI Health Waiver - 2/4/2025 ( (L MASON COUNTY
COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health
415 N 60 Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 9 Beffair: (360)275.4467 ext 400 re Elma: (360)482 269 ext 400
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FAX (360)427-7787
Application for Waiver/Ann FEB 04 T0T5
Amount Paid: C.
Receipt Number:
Instructions _
1. Complete Parts land 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. Applicant/Parcel Identification
Name of Applicant ROIjc2T b(Z,�XLE-a- Telephone 36,0-da0-o�-46L
Mailing Address of Applicant s/ E. S/NCcA/R ®/,
citySNEtTo,J state WA Zip 9PS7 f
12-digit Tax Parcel No. a oti 0 / S _ I _ D O 1 ( O
Site Address SI E. S/AICLA JA P1 S/l,-/-Tea UJA 4gspy
Subdivision Name and Lot CaT 110, TIm Bc lclq k.E AJo. 3f VoLL PSS ld3^lOA
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
❑ Location,WAC 246-272A-0210 ❑ Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
It Mason County Onsite Standards ❑ Departmental Determinations
❑ Other
Description of Waiver/Appeal(include justification,additional material may be attached.):
IKR11L'si AWANGLOP ?tlf P-fce�lecrnc^Nr 7-D HAM A RE5't--R-
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Applicant Signature:Z JJ /C171- Date:
J:WH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
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PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
c Appeal 'Waiver ❑ None required ❑ Class A ❑ Class B ❑ Class C 1� C
2. Identification of Specific Code/Standard/Determination(include date of determination or latest Code/
Standard revision) MCI— 6 --7 r10(„0 04t ) �_ ✓lj�.(� p-e- YY''
3. Nature of Appeal l� 'r
WW r J
4. Hearing Official:
D Board of Health 0 Health Officer
0 Pollution Control hearing Board Public Health Director
0 Certified Contractor Review Board 0 Environmental Health Manager
5. Mitigating Factors:
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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 submitted.
Staff Signature: Date: 7i(co
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:L// l/aw Date:
l:hBH Forms\Waiver-Appeal Mason County Local Revised 120/2017
Pam 2 of 2