HomeMy WebLinkAboutBLD2011-00320 - BLD CD Environmental Health Review - 4/26/2011 i COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number: amink
PO Box 1666 i1 7 Ai
Shelton, WA 98584 Date Received: '30
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 Type of Review
Applicant Rc her t u ,/?P V, Date h Building Permit
Mailing Address Po_Rox ao s .1 M New ❑ Replacement
kk A 9 as z ❑ Commercial Building ermit
City State Zip ❑ New ❑ Replacement
Daytime Phone 360-s7rz z Other Phone ❑ Building/Commercial ermit Revision
❑ Tenant Review
E-Mail Address ❑ Pre-Application
Parcel Information
12-Digit Parcel Number / 1 7 00 3 90
Site Address 3.t 0 Ne Ad'e Name n M e)fa,
Street Number Street City
Type of Job Please submit a scaled plot plan
Describe work on t�u.t,,„ of 1S'n3drP po/e h�,fd.n showing all existing and proposed
building, on-site sewage system,
Number of Bedrooms n and well.
On-Site Sewage Information Water System Information
® On-Site Septic System ❑ New IN Existing Plumbing in structure? ❑ Yes ® No
❑ 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.
Applicant ign ure
Date ��'G - �z
Official use only
Departmental Review Approved I Denied Notes
Water Adequacy
On-site Sewage System II
Tenant Review
Revision
Revised 12/17/09
H �
SJ ,�
J.
N y a7
r
� h
e
a ICI 1
r 1c4
0
cY y
s+
1
J �
ti
Q
4�
U
fi
2
(z s ,
a o v d
SY m Q 4