HomeMy WebLinkAboutBLD2010-01077 - BLD CD Environmental Health Review - 11/17/2010 10300
COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health official use c my
415 N. 6th Street Permit Number:
PO Box 1666
Shelton, WA 98584 Date Received:
Shelton:(360) 427-9670, Ext.400 Amount Received
Belfair: (360) 275-4467 Ext.400
Elma:(360)482-5269 Ext. 400 Receipt Number
Fax (360)427-7787
Applicant Information q Type of Review
Applicant � � —
DateL0 Yommercial
ding Pe it
New7 Replace ent
Mailing Address (7a Of, S044AAAp,
O Buil ing rmit
New O Replace ent
City State Zip
r- D ��g ss3 P¢ t a 0 Building/Commercial P rmit Revision
Daytime Phone Other Phone 0 Tenant Review
E-Mail Address S�EEVz i t>>uN� f191 C! — 0 Pre-Application
Parcel Information
12-Digit Parcel Number aa3p'� Upyw
Site Address
Street Number StreetIllame City
Type of Job 8'13 1 10 Please submit a scale plot plan
showing all existing ar d proposed
Describe work ` ''00 l )06' IQ L,0L SHCL bW 1+ building, on-site sewal le system,
Number of Bedrooms and well.
On-Site Sewage Information Water System Information
On-Site Septic System 0 New ,Fxisting Plumbing in structure? J� Yes 0 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.
Appli t Signature
Date IL oD
Official use only
Depart ental Review Approved Denied Notes
Water Adequacy
On-site Sewage System 3>0 W
Tenant Review
Revision
Revi 12/17/09
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