HomeMy WebLinkAboutWAI2025-00031 - WAI Health Waiver - 5/9/2025 I ?cZSOQ3 (
MASON COUNTY
1_ COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health
415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360) 427-9670 ext 400 Belfair: (360) 275-4467 ext 400 •:• Elma: (360) 482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal pEt
TOWfAmount Paid: l�Receipt Number: 20Zs 0Z'167 MAY 0 9 20
Instructions By W
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 mC�iSsG Q`( x- { Telephone 3GO - c.G�- 'lO 90
Mailing Address of Applicant 4.7SO N Qlc\ 4-a'
City 1 State VGA Zip Ct$c 2-S
12-digit Tax Parcel No. ( 2. 3tt 0 -- Z. -- Q 0 c..), 14 O
Site Address 333` N Q tr1' (Stk t c
Subdivision Name and Lot 1n.t.1,S54,_ (?'ft (-- 1 A Nue\Nk
PART 2: Nature of Waiver/Appeal te
0 Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
❑ Separation ❑ Food Sanitation Requirements
❑ Building Permit Review Policies Gr. 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
0 Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
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Applicant Signature: N Date: S
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only) 61049 a
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
i Appeal yWaiver r None required . 1 Class A ._i Class B :-1 Class C
2. Identification of Specific Code/Standard/Determination nclude date of determination or latest Code/
Standard revision) 114501 covav Dare t ait Cootivt cf tel sfundorcts f r 601 g
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3. Nature f Appeal:
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4. Hearing Official:
l 0 Board of Health 0 Health Officer
0 Pollution Control hearing Board X Public Health Director
t ❑ Certified Contractor Review Board 0 Environmental Health Manager
i
5. Mitigating Factors:
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aLeisi
T wr t( G S a► Cat in, Cc#ifl ecirvr'1 6e weer, fLe +tern
6. I have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted.
2Staff Signature: �% Date: S/[ Z (70Z.r
PART 4: Determination of the Hearing Official
4 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:
15 vY.vrvd crr,1 Date: I J i i
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of 2