HomeMy WebLinkAboutBLD2010-01079 - BLD CD Environmental Health Review - 11/18/2010 00
COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH 'REVIEW
Mason County Public Health Official use only p
415 N. 6th Street Permit Number: �d2olU—OI6C1
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 Number
Fax (360)427-7787
Applicant Information Type of Review
Applicant f#t7(.P 91 Aeeol�% `C OU.4 �' fto i9 ❑ Building Permit
MaiIi ddrenss 30 Z f 5- VvrL 5 Giitro $, rD ❑ New ❑ Replacement
f e �y to ( �r f ❑ Commercial Building Permit
City State Zip ❑ New ❑ Replacement
Daytime I �r1e Other Phone ❑ Building/Commercli`al Permit Revision
❑ Tenant Review
E-Mail Address ❑ Pre-Application
Parcel Information
12-Digit Parcel Number Z Z 3 Df; d 0 0 e 9� 26—
Site Address Fo °F Z Z �(/ / 7!9 6 zs r 4 z&W• ?8t�sc
Street Number Street Name City
Type of Job Please submit a scaled plot plan
Describe work �Q^�-9.P showing all existing and proposed
Number of Bedrooms building, on-site sewage system,
and well.
On-Site Sewage Information Water System Information
IA On-Site Septic System ❑ New WExisting Plumbing in structure? ❑ Yes ff No
❑ 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 G�4ature
� A �1(�n�.a�.-� � Date z 0/U
Official use only
Departmental Review Approved I Denied Notes
Water Adequacy
On-site Sewage System l�t
Tenant Review
Revision
Revised 12t17/09
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