HomeMy WebLinkAboutBLD2010-01101 - BLD CD Environmental Health Review - 12/6/2010 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health official use my
415 N.6th Street Permit Number: I
PO Box 1666 _
Shelton, WA 98584 Date Received:
IZ-
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 In ormation// Type of Review
Applican . o Al N,N N&,4A-V Date-!2t6 I - Building Permit
Mailing Address So 2- L 9e` 4✓-�,�$A-r Jes ❑ New k Replacement
(�„�,,, , 4, , k/A- 15�s y L 7 O Commercial Building Permit
City State Zip ❑ New ❑ ReplacE ment
Daytime Phone zs'i 5-6C <Other Phone ❑ Building/Commercial Permit Revision
❑ Tenant Review
E-Mail Address Pau //lc,✓.M✓ OC'.HoasTill� l— ❑ Pre-Application
Parcel Information
12-Digit Parcel Number 2z 3 3o So 00 / /S
Site Address 3jF1 W.4reW L ✓-� A19 VOL
Street Number Street Name City
Type of Job / Please submit a scalel plot plan
T,r 4 A("Wr/ showing all existing and proposed
Describe work
Number of Bedrooms Y building, on-site sewage system,
and well.
On-Site Sewage Information Water System Information
Sr'&-Site Septic System ❑ New 01E sting Plumbing in structure? 10 Yes ❑ 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.
Ap 'cant S' tur -
Date
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System f
Tenant Review
Revision
Revis A 12/17/09.
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CALF L. TA HJA
LKENSED DE IGNER
EXPIRES:
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