HomeMy WebLinkAboutBLD2011-00104 - BLD CD Environmental Health Review - 2/10/2011 r
COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health offic= i use onl
415 N. 6th Street Permit Number: 13 I61`t011- 00104
PO Box 1666 s
Shelton, WA 98584 Date Received:
Shelton: (360)427-9670, Ext.400 �p
Belfair: (360)275-4467 Ext.400 Amount Received 10, n
Elma: (360)482-5269 Ext.400 Receipt Number c5l abil -A09
Fax (360)427-7787
Applicant Information Type of Review
ApplicantTle_rr Ca-maiwn Date -ID•ll 13-13uilding Permit
Mailing Address 4 NE 91ae's wq!4 ❑ New M�Replacemenl
f3e-141 I r WA $ O Commercial Building Permit
City State Zip ❑ New ❑ Replacement
Daytime Phone 5a9-/34Zther Phone O Building/Commercial Permit Revision
0 Tenant Review
E-Mail Address O Pre-Application
Parcel Information
12-Digit Parcel Number as 31 I-] (o 00/&0
Site Address 141 A/E 5iolrs GUQ_ , 13e1 jr
Street Number StreetAame City
Type of Job Please submit a scaled plot plan
Describe work RP�q( XT�(}} M H showing all existing and proposed
Number of Bedrooms building, on-site sewage system,
and well.
On-Site Sewage Information Water System Information
LR 'On-Site Septic System 0 New Existing Plumbing in structure? es O No
0 Sewer Name of Sewer System If yes:
Using an existing on-site septic system will require a current Please submit a Complete Water
maintenance report and a Record Drawing (Asbuilt). Documents uac Ade Form.
for both of these requirements may be on file with Mason 9 y
County Public Health. Other requirements may apply.
Applicant Signature QQ
�10�5"P/l� SSCi Date
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Official use only
Departmental Review Approved Denied Notes
i Water Adequacy - I( A!✓ �
On-site Sewage System I
Tenant Review
a
t Revision
--/09 _.,.a...
Revisetl 12/1
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