HomeMy WebLinkAboutBLD2010-00857 - BLD CD Environmental Health Review - 9/20/2010 14
_;COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number:'
PO Box 1666
Shelton, WA 98584 bate Received:
Shelton: (360) 427-9670, Ext.400
Belfair. (360) 275-4467 Ext.400 Amount Received 1
Elma:(360).482-5269 Ext. 400 Receipt Number 5 -� 10
Fax (360)427-7787
Applicant Information `/ Type of Review
Applicant_ K USSe11,, �/wletleybate 4�O' y° )3 Building Permit
Mailing Address ZSZ 71V C14r& �o� )� New ❑ IReplacement
u� ❑ Commercial Building Permit
City
y State Zip ❑ New ❑ Replac ment
Daytime Phone ` 24/09 Other Phone 7q/-S°/7L' ❑ Building/Commercial ermit Revision
❑ Tenant Review
E-Mail Address ❑ Pre-Application
Parcel Information
12-Digit Parcel Number 3 O 3/2-2-O00/0
Site Address Z5�0 Al, C/Ar f`tv�
Street Number Street Name City
Type of Job - Please submit alscaled plot plan
'Describe work showing all existing and proposed
Number of Bedrooms building, on-site sewage system,
and well...
On-Site Sewage Information Water System Information
On-Site Septic System *' New ❑ Existing Plumbing in structure? '/RrYes ❑ No
❑ Sewer r 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 'Ad Adequacy for both of these requirements may be on file with Mason eQ y Forma
County Public Health. Other requirements may apply.
Appli t Signa re
Date 9 ZO l
ffi 1 O cia use only
Departmental Review Approved Denied Notes
Water Adequacy Amtp u ho GIC Q
On-site Sewage System Jul(
Tenant Review
Revision
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