HomeMy WebLinkAboutBLD2011-00124 - BLD CD Environmental Health Review - 2/17/2011 � � ZOIn. oo W �—fv rhd rp yu�te lz.
COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH IEVIEW
Mason County Public Health Official use my
415 N. 6th Street Permit Number: 001
PO Box 1666
Shelton, WA 98584 Date Received: 2.- 7. 2011
Shelton: (360) 427-9670, Ext. 400 Amount Received o0
Belfair: (360) 275-4467 Ext. 400
Elma: (360) 482-5269 Ext. 400 Receipt Number O D
Fax (360) 427-7787
Applicant Information Type of Review
Applicant ih, cl (kL4 AklblAn&L_So atea—lco—II Building Permit
Mailing Address PO X New o Replacement
ke.Uflorf' 1/' [ 0 Commercial Building Permit
City State Zip O New O Replacement
q'7
Daytime Phone_ Other Phone 07�50�1 0 Building/Commercial Permit Revision
O Tenant Review
E-Mail Address Jw I atktr 23 ® ydkoo p Pre-Application
Parcel Information
12-Digit Parcel Number 3 3 (Sc� o00 3O
Site Address la t S U) r Jr
Street Number Street Name I City
Type of Job Please submit a scaled plot plan
Describe work showing all existing and proposed
Number of Bedrooms building, on-site sewage system,
and well.
On-Site Sewage Information:=- Uu�' n Water System Informa ion
g 3 F-S- Y
Re-On-Site Septic System New O Exis ing Plumbing in structure? lYYes O No
C3 Sewer Name of Sewer System If yes:
Using an existing on-site septic system will require a current Please submit a comp eted 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.
A plicar}t Sigrtature
cJcQ�� u1Sv>` Date
Official use only
Departmental Review Approved I Denied Notes
Water Adequacy
On-site Sewage System
Tenant Review
Revision
Revise 12/17/09
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