HomeMy WebLinkAboutBLD2010-01079 - BLD CD Environmental Health Review - 11/18/2010 103. pO
COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only 415 N. 6th Street Permit Number: �c12010—���rG�
PO Box 1666
Shelton, WA 98584 Date Received:
Shelton: (360) 427-9670, Ext.400
Belfair: (360) 275-4467 Ext. 400 Amount Received �j J
Elma:(360)482-5269 Ext. 400 Receipt Number
Fax (360)427-7787
Applicant Information Type of Review
Applicant 91/r71P 9eAeAe iotU( 9. to i7 ❑ Building Permit
Mai1g ddress_3 D Z IS- y, tD ❑ New ❑ Replacement
f'x a Q ll�cu, Gvrlf. ire ❑ Commercial Building Permit
City State Zip ❑ New ❑ Replacement
Daytime , 1 g9el_2 3 7 Z_ ❑ Building/Commer�al Permit Revision
Yt Other Phone
E-Mail Address ❑ Tenant Review
❑ Pre-Application
Parcel Information
12-Digit parcel Number Z Z 3 O S d 0 0 l9 o2yL —26—
Site Address Fa 'V Z z- / l.,ue k Al 7l9 4
?w'o-osa
Street Number Street Name City, j
Type of Job Please submit a scale plot plan
Describe work - if q Q showing all existing and proposed
Number of Bedrooms- building, on-site sewage system,
and well.
On-Site Sewage Information Water System Information
On Site Septic System ❑ New )Nzxisting Plumbing in structure? ❑ Yes No
❑ Sewer Name of Sewer System
If yes:
Using an existing on-site septic system will require a current
maintenance report and a Record Drawing (Asbuilt). Documents Please submit a completed Water
for both of these requirements may be on file with Mason Adequacy Form.
County Public Health. Other requirements may apply.
Applicant Signature
Date ZO/U
Official use only
Departmental Review A roved Denied Notes
Water Adequacy
On-site Sewage System Z�t
Tenant Review
Revision
Revised 2I17I09
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