HomeMy WebLinkAboutSWG2010-00479 - BLD CD Environmental Health Review - 6/18/2010 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only G�
415 N. 6th Street Permit Number:
PO Box 1666
Shelton, WA 98584 Date Received:
Shelton: (360)427-9670, Ext. 400
Belfair: (360) 275-4467 Ext. 400 Amount Received
Elma: (360)482-5269 Ext. 400 Receipt Numberac'ZZ- co -) >
Fax (360) 427-8442
Applicant Information Type of Review
Applicant�pX eEa U �l d Date al Building Permit
Mailing Address ?-'541 NW glow ft 0 New L9' Replacement
5e.6-�fl C_ W R 9g11-7 0 Commercial Building Permit
City State Zip 0 New 0 Replacement
'Wo- rTSQ_- 0 Building/Commercial Permit Revision
Daytime Phone S5L -1 Other Phone
0 Tenant Review
E-Mail Address 0 Pre-Application
Parcel Information
12-Digit Parcel Number 22233 . 52 . 00901
Site Address 30L+1 E M-aScrn LcLKr✓ Dr E �a raneVI e1-w
Street Number Street Name City
Type of Job Please submit a scaled plot plan
Describe work R IO c u ua e XI iYW hz ' e, Lai rjca showing all existing and proposed
building, on-site sewage system,
Number of Bedrooms 2 and well.
On-Site Sewage Information Water System Information
0'On-Site Septic System 19 New 0 Existing Plumbing in structure? M"Yes 0 No
0 Sewer Name of Sewer System If yes:
Using an existing on-site septic system will require a current Please submit a completed Water
maintenance report and a Record Drawing (Asbuilt). Documents Adequacy Form.
for both of these requirements may be on file with Mason
County Public Health. Other requirements may apply.
Applicant Signature
Uia> Date (01 151/0
Official use only
Departmental Review Approved Denied Notes
Water Adequacy r. p
On-site Sewage System �' /V (u ou AL41 11 /vn
Tenant Review
Revision
Revised 12/17/09
MASON COUNTY
PUBLIC HEALTH
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275-4467
Application for Determination of Adequacy FAX(360)427-8442
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully completed.
2. Complete only the portion of Part 2 applying to the type of water system utilized.
3. Submit completed application, with attachments, to the health department for review.
PART 1: Applicant/Parcel Identification
Name of Applicant Tle `ems- Gnaw Ic) Date
Mailing Address 2341 NW 910th �Pt Telephone 2-06-782' 85LF
5r. trl c. W R 98117 22233 • 5 2• ooQo/
Assessor's Parcel Number
Type of Water System Check One): Reason for Application Check One):
cwr Public/Community Water System(2 or more 61, Building permit
connections)" ❑ Land use application, if so..
❑ Individual water source(one connection), ❑ Division of land:
if so..
u Well #of Parcels?— SPL_
L Spring/surface water ❑ Boundary line adjustment
❑ Other(explain) ❑ Other(explain)
.. If you have more than one residence Replacement(please indicate name of water system
connected to this well,check the Public box. below if applicable—no signature required)
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Public Water S stem
Name of Water System
Water Facility Inventory (WFI) Number:
(write "none"for two party)
❑ I am the manager of this water system. The water system has been approved for services.
There are presently connection(s)in use. This will be the connection.
❑ lam the manager of this system. This connection will be to up ade or change the use ofan
existing connection on this system(ie: recreational to full timef Please indicate on the following
line the nature of this change:
This water system is able and willing to provide water to this(these)connection(s)witho t
exceeding the limits of the water system or any limits set by state and local regulation.
Signature of Water System Manager Date
C:IDOCUA&NTSAND SEMNGSIRLRIDESKTOPIWA TER ADEQUACr.DOC Update;April 2006