HomeMy WebLinkAboutPAR2010-00046 - BLD CD Environmental Health Review - 12/30/2010 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use oily
415 N. 6th Street Permit Number: Al2. 10
PO Box 1666
Shelton, WA 98584 Date Received: I I U
Shelton: (360)427-9670, Ext. 400 Amount Received i"311
Belfair: (360)275-4467 Ext. 400
Elma: (360)482-5269 Ext. 400 Receipt Number
Fax (360)427-8442
Applicant City plicant Information L Type of Review
Applicant o'- ✓. t �Date (Z-3o-/ 0 Building Permit I
Mailing Address n^ �ib rc t ll 0 New 0 Replacement
R-e 1�. .y (AI A c�c�G;2 Commercial Building Permit
0 New � Replacement
460 �3 i `F � State Zip toy 0 Building/Commercial Permit Revision
Daytime Phone Other Phone O Tenant Review
E-Mail Address tea) �� � ��� 10 Pre-Application
Parcel Information
12-Digit Parcel Number ( 2 — 2 - /
Site Address �a G1000 241-2 NC S JCit 5Z �
Street Number Street Name y
Type of Job Please submit a scale plot plan
lQ� t showing all existing and proposed
Describe work Slav �> �3t' �o✓mac' building, on-site sewage system,
Number of Bedrooms ' s and well.
On-Site Sewage Information Water System Information
0 On-Site Septic System O New 0 Existing Plumbing in structure? 1 O Yes No
JZ Sewer Name of Sewer System If yes:
Using an existing on-site septic system will require a current Please submit a comp leted Water
maintenance report and a Record Drawing (Asbuilt). Documents Adequacy Form.
for both of these requirements may be on file with Mason n ,/ �� 1�
County Public Health. Other requirements may b apply. �j.e ( ,Y ,,1
icant Signature
� Date
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System
Tenant Review
Revision
Revi ed 12/17I09
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