HomeMy WebLinkAboutWAI2025-00043 - WAI Health Waiver - 6/13/2025 4
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0`� ti` {1 MASON COUNTY
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, COMMUNITY SERVICES
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t°,y y' Building,Planning,Environmental Health,Community Health
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415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 •:• Belfair: (360) 275-4467 ext 400 Elma: (360)47,- - .9 ext 400
FAX (360)427-7787 / E
Application for Waiver/Appeal 0EQ V
Amount Paid: il ZOO JUN
Receipt Number: ZOZ�-030 1 20 5 8
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Instructions loAtr 2026 ` �� (43 y �i;l,, ,
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. 1
3. Submit completed application with attachments to Mason County Public Health for review.
fOir 5W6 to z- 4OOf°1
PART 1. Applicant/Parcel Identification
Name of Applicant M I+G h Ar d e-c So n/Alp1A Telephone 360" 970 -1 2-3-5
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Mailing Address of Applicant f 31 68 4 /t•I4-
City (>/ m pot, State C" Zip 9e5/6
12-digit Tax Parcel No. 2 Z 2- i 1 -- 3 0 -- 0 0 0 0 Z
Site Address g 10 j NE Wori'1,. Storer kd
Subdivision Name and Lot Ae I A re, Le,ve- i r Z
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
la Separation 0 Food Sanitation Requirements
❑ Building Permit Review Policies 0 Group B Water System Regulations
❑ Location,WAC 246-272A-0210 0 Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
O 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: Jy� j Date: 7/31 J 2-5
J:1EH Fonns\Waiver-Appeal Mason County Local Revised 1/20/2017
Page I of 2
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PART 3: Public Health Evaluation (Staff Use Only) tOCCi
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
Appeal Waiver - None required Class A • Class B Class C
2. Identification of Specific Code/Standar / Determination (include date of determination or latest Code/
Standard revision) w$GZY6•l?k_ -OZ10
3. Natu e of Appeal:
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4. Hearing Official:
❑ Board of Health 0 Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
O Certified Contractor Review Board ff Environmental Health Manager
5. Mitigating Factors:
-t� pft.pelfr 1t" 1s naf cloy/1 raa�''e,�f otc dr'vAtelI
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:
Date: 07/Z6 a5
PART 4: Determination of the Hearing Official
l�--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: Date: /517-.1‘
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of 2
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