Loading...
HomeMy WebLinkAboutWAI2025-00071 - WAI Health Waiver - 9/10/2025 ` goqi MASON COUNTY ,1►. COMM UNITY SERVICES j A*a Building,Planning,Environmental Health,Community Health IrZ:>•Ill IVO 415 N 6`h Street, Bldg 8, Shelton WA 98584, Shelton: (360) 427-9670 ext 400 Belfair: (360)275-4467 ext 400 Elma: rye stc� "• '�• ��r' FAX (360)427-7787 Application for Waiver/Appeal P 1 ti 2025 Amount Paid: 9.0° Receipt Number: & 045/3 By CW"� Instructions toA\ CSC 31 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 Telephone .,,>L Mailing Address of Applicant l' .,pct • `i)!"' l c State (AJ Zip cp..City �-��tsr,- ° -vv-W nn J zip 12-digit Tax Parcel No. 0 c�, © 1 ca -- I Q -- 1 0 _ Site Address I''-I .`';(;) t'. 1 /o& Subdivision Name and Lot PART 2: Nature of Waiver/Appeal ❑ Contractor Certification Requirements ❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists) ❑ Separation 0 Food Sanitation Requirements ❑ Building Permit Review Policies O Group B Water System Regulations Location, WAC 246-272A-0210 O Water Adequacy Requirements ❑ Holding Tank WAC 246-272A-0240 O Enforcement Timelines ❑ Mason County Onsite Standards O Departmental Determinations ❑ Other Description of Waiver/Appeal (include justification, additional material may be attached.): Lam/ firs P C r 4 r r stn t, z_ mac. lit -1-19J„,(2.42 r� c� Applicant Signature: �i Date: 9 _A J:\1311 Forms\Waiver-Appeal Mason County Local Revised 1/20/2017 Page 1 of2 PART 3: Public Health Evaluation (Staff Use Only) ,or f 1. Type of Determination Required: Type of Onsite Waiver(if applicable) 1 Appeal Waiver u None required 11 Class A u Class B n Class C 2. Identification of Specific Code/Standard/Determination (include date of determination or latest Code/ Standard revision) DIC 2'16'27?19- 01..11.1(Lt)(4) 3. Nature of Appeal: �4 1 � +�t t��r.��P 1om��f+�tr,�f{.3b 5 G �r �ri �j2r�lckeS� (4s/err)t l�nS� t ''' 4. Hearing Official: ❑ Board of Health O Health Officer ❑ Pollution Control hearing Board O Public Health Director ❑ Certified Contractor Review Board (X Environmental Health Manager 5, Mitigating Factors: r ▪ Xt1 s li ce d a d ouid swte 0 i' ' from the Co r (Q 1 5t, test ertabt - gerctiib- ecfctelt4 ite � �,, �� I t is >`r t 'ri � �'' " r •, t to Ii U. • l + rlc c' 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: //J. 17Z, (?o?r PART 4: Determination of the Hearing Official 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: O 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: VI J:\EH Fonns\Waiver-Appeal Mason County Local Revised 1/20/2017 Page 2 of 2 AISIIIIIIINIMIII • • t • • • M•► . a • • •• • a/� • .0 40 • • • • a ♦, a ♦ • a ai ,, > 4 A.- . + _fri.-NA 047 \-,,,.jkir A.1•1SVNIV, j-nis,0 7 ai ..... ..•___ .aaa a ..ma. ..m....s add .,a ■.,.s a...sa.d a m. _ate.r . _samo mod ammo edict j mr-ri1/41 d ----.11,1„) ALT P 'Attie 1 ,I. ,./th sP i "-",--r-I tr Aft *. %kii,,S, ' ''''1 \\ ' , '011 Qt