HomeMy WebLinkAboutBLD2010-00812 - BLD CD Environmental Health Review - 6/30/2010 i o3. o0
COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use conly
415 N. 6th Street Permit Number:
PO Box1666
Shelton, WA 98584 Date Received: l b
Shelton: (360) 427-9670, Ext. 400 Amount Received
Belfair: (360) 275-4467 Ext. 400
Elma: (360) 482-5269 Ext. 400 Receipt Number �SLeo�
Fax (360) 427-7787
Applicant Information Type of Review
Applicant A W)Ct ORS DateLc ZC6fb 0 Building Permit
Mailing Address 5540'4 I�G r �Oc� i7� • o New 6 &placernent
n�Qn � � gg 31 a 0 Commercial Building F ermit
City State Zip 0 New ❑ Replace ent
` j-822,rl 0 Building/Commercial F ermit Revision
Daytime Phone Other Phone O Tenant Review
E-Mail Address O Pre-Application
Parcel Information
12-Digit Parcel Number IG�-` 50 - GAS
Site Address Yl
Street Number Street Name
Type of Job Please submit a scaled plot plan
Describe work showing all existing and proposed
T building, on-site sewage system,
Number of Bedrooms 1 and well.
0 Site Sewage Information Water System Information
� On-Site Septic System 13 New a'Existing Plumbing in structure? fit" es O No
O 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
Date 6-30 - ,20Z0
Official use only
Departmental Review Approved Denied Notes
1 - 1
Water Adequacy �r�G 2v"_0A d�
On-site Sewage System e Z tp
Tenant Review
Revision
Revis d 12/17/09
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