HomeMy WebLinkAboutBLD2010-00523 - BLD CD Environmental Health Review - 6/25/2010 COMMUNITY DEVELOPMENT ENVIRONMENTAL 'HEALTH REVIEW
Mason County Public Health Off"c!•,�d usse�only _
415 N. 6th Street Permit Number:
PO Box 1666 /
Shelton�584 Date Received: �-
Shelton: (360)427-9670, Ext. 400 Amount Received ( � Q
Belfair: (360)275-4467 Ext. 400 l _•
Elma:(360)482-5269 Ext. 400 Receipt Number S V
Fax (360)427-8442
Applicant Information Type of Review
Applicant b Leof-_.ram- Date 2-3 10 0 Building Permit
Mailing Address Z-SIYo c.dt Lt4-s S't-SW , -1:1`-1 Ok o New O Replacement
Lfit� wol q•5�. 2 E3 Commercial Building Permit
City State Zip O New 0 Replacement
`'FF"# cc(I O Building/Commercial Permit Revision
Daytime Phone.3co-agz"2W&Other Phone3G4-YS/-S-381
O Tenant Review
E-Mail Address &4, je C%k"eA f �//,fir• O Pre-Application
Parcel Information
12-Digit Parcel Number�Z[�� S r) 7
Site Address :�Q ( 5L 5/'C /�d-h .
Street Number Street Name City
Type of Job Please submit a scaled plot plan
Describe work �cihoc�c� �cof pdtr�� showing all existing and proposed
building, on-site sewage system,
Number of Bedrooms and well.
On-Site Sewage Information Water System Information
On-Site Septic System O New [)(Existing Plumbing in structure? jKYes E3 No
El Sewer Name of Sewer System If yes: (A.P�
Using an existing on-site septic system will require a current Please submit a completed Water
maintenance report and a Record Drawing (Asbuilt). Documents
for both of these requirements may be on file with Mason Adequacy Form.
County Public Health. Other requirements may apply.
Applicant ligqature / /
Date o! 3 p
Official use only
Departmental Review Approved I Denied Notes
Water Adequacy la Z-
On-site Sewage System <_'4:ZA� /
Tenant Review
Revision
Revised 12/17/09