HomeMy WebLinkAboutBLD2011-00035 - BLD CD Environmental Health Review - 1/14/2011 oly i b�.COD
COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use c my
415 N. 6th Street Permit Number: 1�ld2,011-
PO Box 1666
Shelton, WA 98584 Date Received:
Shelton: (360) 427-9670, Ext. 400 0�
Belfair: (360) 275-4467 Ext. 400 Amount Received
Elma: (360) 482-5269 Ext. 400 Receipt Number O t
Fax (360) 427-7787
Applicant Information \Tyne of Review
Applicant Date} [ � Building PeKrryt�
Mailing Address d� � '� S-t- jk) l� D New ld Replacement
( rba.-- 01 ol D Commercial Building Permit
Cit State Zip D New D Replace ent
3- a 36ther Phone aS3 da -'.X135� O Building/Commercial P rmit Revision
Daytime Phone "
D Tenant Review
E Mail Address D Pre-Application
Parcel Information 12-Digit Parcel Number IA3 `J A 0 QCr)G, Sj�/
Site Address 2.'7nn '� in In c l Srn ith Rd Tip h �� jiff 4rt5�
Street Number Street Name City
Type of Job Please submit a scaled plot plan
Describe work I fyte.r'n✓ y_Q,v\nc, showing all existing and proposed
building, on-site sewage system,
Number of Bedrooms _ and well.
O Site Sewage Information / Water System Informatt/Yes
VOn-Site Septic System D New m Existing Plumbing in structure? D No
D 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.
Applic ignature
Date
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System
Tenant Review
Revision
Revise 12/17/09
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