HomeMy WebLinkAboutBLD2011-00043 - BLD CD Environmental Health Review - 6/8/2011 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number:
PO Box 1666
Shelton,WA 98584 Date Received: �' {
Shelton: (360)427-9670, Ext.400
Belfair: (360)275-4467 Ext.400 Amount Received
Elma: (360)482-5269 Ext.400 Receipt Number
Fax (360)427-7787
Applicant Information n�^ Type Of Review
Applicantt Date 0 ding Permit
Mailing Address 3�/c7D Seluo �GL Q2AD New O Replacement
T�.E t_� /e:2/ )+ elk sag 0 mercial Building Permit
City State Zip New 0 Replacement
4bO 0 Building/Commercial Permit Revision
Daytime PhoneXo -)77 Other Phone
O Tenant Review
E-Mail Address C7L Ro.DSzc0V_ 30. 66t/ 0 Pre-Application
Parcel Information
12-Digit Parcel Number
Site Address
Street Number Street Name City
Type of Job pp Please submit a scaled plot plan
Describe work ..,YER��y h �iil Gr �iet FNNz/sl showing all existing and proposed
Number of Bedrooms .--®'— building, on-site sewage system,
and well.
On-Site Sewage Information Water System Information
O On-Site Septic System 0 New 0 Existing Plumbing in structure? 0 Yes 0 No
O 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
for both of these requirements may be on file with Mason Adequacy Form.
County Public Health. Other requirements may apply.
Applicant Sign �Ay,�7
2 r�0 Date 6�Ff'Li
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System (o I O t I
Tenant Review
Revision
Revised 12/17/09
L��Ioo
e
a
�MWfJApPROVEU
A ;