HomeMy WebLinkAboutWAI2025-00019 - WAI Health Waiver - 3/26/2025 MASON COUNTY
COMMUNITY SERVICES
Building,Planning,Enodronmenual Heeldt Community Health
415 N Elu Street, Bldg 8,Shelton WA 98584,
Shelton: (360)427-9670 ext 400 : Belfair:(360)275-4467 ext 400 0 Elma: (360)4825269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal lem
Amount Paid: � 305Receipt Number: 20Z'S' 01 14
Instructions Wf :r 202,5 -Q '�1q
1. Complete Parts 1and 2. No determination can be made until these parts are fupleted.
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
Name of Applicant .�t . ",11.v-r'.z1 Telephone 3(¢17 --7S'3- 12tL
Mailing Address of Applicant ?-( - Z's ( 6-L-
City O��f State-"_ Zip 48 So-7
12-digit Tax Parcel No. 3 2 O '2-- _ (� _ 'L d
Site Address 3-f 1 E . �4 nl�A a nti 4 L7fZ
Subdivision Name and Lot S"0V?'6CAC-C-JT T62'RA_C-Lr 3�PAA1 51-Y. 2- Lt,o
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
❑ Mason County Onsite Standards ❑ Departmental Determinations
❑ Other
D� �Description of Waiver/Appeal(include justification,additional material may be attached.):
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Applicant Signature: Date:
1:\EH Fomu\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 1 of 2
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 2 Class B � Class C
2. IdentRicatl of Speclflc Code/Standard/Determination (include date of determination or latest Code/
Standard revision)
3. Nature of Appeal
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4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board -D(,,Environmental Health Manager
5. Mitigating Factors: Q ?rl�t�f-
6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted,
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Staff Signature: t T , Date: �� 1
PART 4: Determination of the Hearing Official
12L,The hearing official has determined that approval of this request will not adversely affect public health and
is hereby®ranted.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: L /1S
1:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of 2
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