HomeMy WebLinkAboutWAI2025-00016 - WAI Health Waiver - 3/17/2025 col
MASON COUNTY
COMMUNITY SERVICES
Building.Planning,Environmental Heald,Cora nunity Health
415 N 61h Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 •> Belfair: (360)275-4467 ext 400 0o Elma:(360)482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid: =
Receipt Number:
Instructions
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 Publlc Health for review.
PART 1. Applicant/Parcel Identification
Name of Applicant Il N £brig, LV Newrv.J Telephone 310 9 r I z'i-b
Mailing Address of Applicant 4431 LfYaa.- Avg jo L
City 0 t State W Zip
12-digit Tax Parcel No. �- 7 -- __5 - - � _0 � t� —
Site Address o �`7A I le E I T H R D
Subdivision Name and Lot LA K L L/Jt4 wt 4 R I C fc /� lO-T 6
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in vertical (Installer, Pumper,O&M Specialists)
L47 Separation ❑ Food Sanitation Requirements
Cl 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
Description of Waiver/Appeal(Include justification, additional material may be attached.):
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Applicant Signature: �/� Date: ra
JAEH Foci Waiver-Appeal Mason County Local / Revised 1/20/2017
Page 1 of2
PART 3: Public Health Evaluation (Staff Use Only) /
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1. Type of Determination Required: Type of Onsite Waiver(if applicable)
❑Appeal ?(Waiver ❑Nam required ❑Class A ❑ Class B ❑Class C
2. Identification of Specific Code/Standard/Determination(Include date of determination or latest Codel
Standard revision)
3. Nature of Appeal:
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: 4eU,44hd/41
6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted('. /1 I '
Staff Signature: L W b Date: 3—`� ^+/a'
PART 4: Determination of the Hearing Official
d'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 �� Date: 3 07 2.l
f\RH Fonos\Waiver-Appeal Meson County Local Revised 1202017
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