HomeMy WebLinkAboutWAI2025-00013 - WAI Health Waiver - 2/24/2025 MASON COUNTY
COMMUNITY SERVICES
Building,Planning,Environmental Health Community Health
415 N e Street, Bldg 8, Shelton WA 98584,
Shellon: (360)427-9670 ext 400 4 Belfair. (360)275-4467 ext 400 4 Elma: (360)4825269 ext 400
FAX (360)427-7787
Application for Waiver/ _peal
Amount Paid: FES p`/202
Receipt Number. 20Z-5,- X177� RE 5
�fIVED
Instructions
1. 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. Applicant/Parcel Identification
Name of Applicant tyh. �VNT6R— Telephone 3(" jS3-\yZro
Mailing Address of Applicant l\ -k-
city C`Y State WA ZIP gGS�:Z
12-digit Tax Parcel No. Z Z
Site Address 5(a0 " ?RotS1L'ii�r tC�
Subdivision Name and Lot r-0t b SP 54ro
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
Q Location,WAC 246-272A-0210 ❑ Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Onsite Standards Departmental Determinations
❑
Description of Waiver/Appeal(include justification,additional material may be attached.):
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VSTsD S1M � 1 `++Applicant S Date: � -'Ld - LS
1:,EH Forms,Waiveasoo aunty Local Revised 1/20R017
Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
E Appeal �Naiver ❑ None required Class A D Class B n Class C
2. Identification of Specific Code/Standard/Determination(include date of determination or latest Code/
Standard revision) wn , r Z � 10
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3. Nature of Appeal: e A.0
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4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board q Public Health Director
❑ Certified Contractor Review Board Environmental Health Manager
5. Mitigating Factors:
6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been
submitted.
,c/L,,, �1 7.�
Staff Signature: ��I Ulm' ' V b ' V ' Date: 3 G�
PART 4: Determination of the Hearing Official
U). 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 wndrtions:
Hearing Official Signature: Date: ✓
J:\FH Forms\Waiver-Appeal Mesoe County Local Revised 1202017
Page 2 of
• , Granting Waivers from State On-Site Sewage System Regulations Chapter 246-272A WAC
Effective Date: July 1,2007 Revised April 2017
On-Site Sewage Systems (Chapter 246-272A WAC)
Re Quest for Waiver from State Regulations
r" € (completed by applicant)
Name: (1) tJ 1 t M r , T� Local Health Deportment/District (1)
M see instructions
Address: P. O • awX `�i
OLI WA,. ct6gol
Telephone: (3(qp) -793 - L1't-la
Signature:
Property l tification: (3) A 7 'L L 116
C[ n E pRA Ql4R—T L�
wT O SP 540
Section I1. (completed by applicant)
WAC Number. (4) WACRequiremem: (5) Waiver Sought (6)
246-272A— O-L10 A tdU(f.'tsaN( airtr LM So tRU tkiwN -C.
Subsection: No PV LrL W0—t_
Justificafion(mitigafionmeasurestobeprovided): (7) (-t.46 tIA Sc.y40 C-AS s+.ib W.-[alr
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Section M. I (completed by health officer)
Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9)
Comments/Conditions: (10)
Type of Waiver: (11) ].Class A [ ]Class B [ ]Class C—Request DOH review efm granting? Ycs_ No
Neighbor Notification: (11) Required? Yes_ No_ Ifneeded are agreements,easements,etc.properly fAed? Yes _ No
$action lV. (campletedbyheaith officer)
This Reques[For Waiver From Store Regulations has been reviewed according m the provisions of Chapter 246-272A WAC On-Site
Sewage Systems. The review criteria applied,and the mitigation measures proposed and/or required,have been evaluated for their ability
to provide public health protection at least equal to that provided by this chapter WAC.
I ] Denied t Approved/Granted—Subject to all comments,conditions and requirements noted in Sections H and 1D.
Local Health Officer (13) Date:
DOH 337-021 Page 26 of 32