HomeMy WebLinkAboutBLD2011-00238 - BLD CD Environmental Health Review - 4/1/2011 COMMUNITY DEVELOPMENT
ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number: Jyi—dz�—
PO Box 1666 A4 _1 - 9b I I
Shelton, WA 98584 Date Received:
Shelton: (360) 427-9670, Ext. 400 Amount Received
Belfair: (360) 275-4467 Ext. 400 I
Elma: (360)482-5269 Ext. 400 Receipt Number `
Fax (360) 427-7787
Applicant Information Type of Review
Applicant `3► G � �n�! Date �.'J21 81""BuilSlirlgPermit
ter New O Replacem@nt
Mailing Address 7 6 � � � �'� 7��"
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G U-os -q 1 6 0 O Commercial Building Permit 0 New 0 Replacem nt
City State Zip
O Building/Commercial P rmit Revision
Daytime Phone Other Phone Ago-?2/J'322 0 Tenant Review
E-Mail Address 0 Pre-Application
Parcel Information
12-Digit Parcel Number f :2 " 00Iloo
Site Address /`� NT S D�� u
Street Number Street Name 0�
Type of Job Please submit a scaled plot plan
showing all existing an proposed
Describe work building, on-site sewage system,
Number of Bedrooms and well.
On-Site Sewage Information Water System Information
W-On-Site Septic System ❑ New xisting Plumbing in structure? 10'Yes ❑ No
0 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.
Applica t k!9.9,aWre r
Date
Official use only
Departmental Review A roved Denied Notes
Water Adequacy
On-site Sewage System 7l0
Tenant Review
Revision
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