HomeMy WebLinkAboutWAI2025-00031 - WAI Health Waiver - 5/9/2025 (2) I ? ZYOdO3
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MASON COUNTY
COMMUNITY SERVICES
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Building,Planning,Environmental Health,Community Health
415 N 61h 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 PECEOYE0
Amount Paid: t
Receipt Number: 2025-- 0240 MAY 0 9 20 -
Instructions B �A
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111
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 md_i S,Sc._. \y t Telephone %O ' &O' ''O 9
Mailing Address of Applicant 47s0 A.) Oic'. &Ago,: 11wN
City State (pJA Zip ek$�o Zg
12-digit Tax Parcel No. 1 2, 3 0 -- l{ Z. -- O 0 0 r d
Site Address 3 33 I Al E Q tel� (n Jtl44.Z c 144.A.Ai
Subdivision Name and Lot 11(1,t_A SSc, ,r- -j ` i•J(1;Cc, (*e\\.(
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
❑ Separation 0 Food Sanitation Requirements
0 Building Permit Review Policies Er Group B Water System Regulations
❑ Location, WAC 246-272A-0210 0 Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
❑ Mason County Onsite Standards 0 Departmental Determinations
❑ Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
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Applicant Signature: INV Date: S
J:\EH Forms\Waiver-Appeal Mason County Local T Revised 1/20/2017
Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only) 6rQve a
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
c Appeal 'Waiver F. None required .i Class A n Class B L. Class C
2. Identification of Specific Code/Standard/ Determination nclude date of determination or latest Code/
Standard revision) ln45� C f O��G h elf(:)
c(�t� S f�d 1`�, for E7i�P
3. Nature f Appeal: �4 sy� , 7
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as*Gas Op acre, faO. Q'f QG rr$ fie p j,i 1 Z atef z zw.
4. Hearing Official:
❑ Board of Health 0 Health Officer
❑ Pollution Control hearing Board 111 Public Health Director
❑ Certified Contractor Review Board 0 Environmental Health Manager
5. Mitigating Factors:
- Porte ( 1a3o9Y200120 is qLb o54 an aCIE, Co.Q( gays) and Parcel
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- T k't ( G s G+'f �r /01, Ccain e°GO t.�e� fite_ 111.r6
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6. I have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted.
Staff Signature: 1,2" Date: SG /L a zs-
PART 4: Determination of the Hearing Official .
Ali 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:
El 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 'W A vJrry'1 Date: �~ )' J IJ Z`)
J:\EH Fornns\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of 2