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Home My WebLink AboutWAI2022-00051 - WAI Health Waiver - 4/19/2022 QUN 415 N.6"STREET,SHELTON WA 98584 SHELTON:360-427-9670,ext 400 [M SERVICES BELFAIR:360-275-4467,ext.400 COICA w a aim ca mmrou wm ELMA:360-482 5269,eid.400 FAX:360427-7798 cation for Waiver or Appeal rUAA Amount Paid: . Receipt Number: . . - �`� - 2022 I� WAI�y11• Q0asi Instructions: -- - 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 t. Applicant& Parcel Information Name of Applicantn - y� c Mailing Address -23J F city A16v I state VV A zip °18 sg L7/ Parcel No. Site Address 5 � � P 4� {-- Subdivision Name and Lot 1 ('Yk6 I ci az-- I—D 2� PART 2: Nature of Waiver/Appeal ❑ Onsite: Class A Waiver ❑ Food Sanitation Requirements ❑ Onsite: Class B Waiver ❑ Group B Water System Regulations q, Onsite: Class C Waiver ❑ Water Adequacy Requirements Onsite: Location,WAC246-272A-0210 ❑ Building Permit: EH Review Policies Onsite: Holding Tank,WAC246-272A- ❑ Appeal:Enforcement Timelines 0240 ❑ Appeal:Departmental Determinations ❑ Onsite: Contractor Certification ❑ Other Requirements Description of Waiver/Appeal(include justification, additional material may be attached.): AYi N ✓\ /oin)I Applicant Signature: Date: Revised 8/13/2018 This form may be scanned and available for public view on the Mason County Web site. Page 1 of i PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) Appeal *aiver ❑ None required j6(p,, ❑ Class A ❑ Class B ❑ Class C 2. Identification of Specific Code/Standard/Determination (include date of determination or latest Code/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 Manage 5. Mitigating Factors: fAQ S. 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: 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: ❑ 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: Health Official Signature: Date: Revised 8I73Qn18 This form may be scanned and available for public view on the Mason County Web site. Page 2 of RECEIVED �jC.O 021 `OI 221 AUG - 32021 Aovaoai - oo ��8 615 W. Alder Street •w �a raoa�- OD653 Gaua 0 _ p03a5 - P LANT�C QI ,I j v 'T&5erJ. ISRkkCN Awes ate WT DIvx �y 61' [�RFGEY" 27 -SD-pen'o3'F - A-ra 6 MIw jp0n,°.4».x ; NO �:v%ny Sf'YNGf'rt Ye F' r• J i IrD U/t G�Iy�EY Si e,/ (% 3G or 39'}. 5i43A �ro �sse� _ 6 peA PLANNING: u _ _ -- - - - A '� L SETBACKS ARE MEASURED '( H " o �a FROM THE FURTHEST � s ✓ ` Cgw�Ae i ?&low ItP e PROJECTION OF THE BUILDING m -k p iI Leo' f 30A �OV MASON COU'.', Y UC! ! LANNINk SITE PLAN REO L!-'.EJ T B ON SITE CHANGES SUB,-- TO A ROVAL 1 yy--�� m a,v,w�e Lithe ;,AI.Aw- L'v Z '�C 3�b�1FD LIAl�S KIL IAaDie � Ca��:: a � �© �: ��✓� esepVE AR&A