HomeMy WebLinkAboutBLD2011-00671 - BLD CD Environmental Health Review - 8/10/2011 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 Amount Received .�
Belfair: (360) 275-4467 Ext.400
Elma: (360)482-5269 Ext.400 Receipt Number
Fax (360)427-7787
Applicant Information Li1WLa4h, Type of Review
Applicant lL Datea-10-I I Buil ' g Permit
New o Replacement
Malli g Address�i 0•
r5 �- a Commercial Building Permit
ity State Zip O New 0 Replacement
67L O Building/Commercial Permit Revision
Daytime Phone Other Phone O Tenant Review
E-Mail Address O Pre-Application
Parcel Information
12-Digit Parcel Number�vZav31 - v2a - C6000
Site Address %, { In r ni0L 5 11 \/
Street Number Street Rame City
Type of Job Please submit a scaled plot plan
Describe work 1 I rn I,L 6 L l/1� n showing all existing and proposed
building, on-site sewage system,
Number of Bedrooms _ and well.
On-Site Sewage Information Water System Information
On-Site Septic System O New XExisting Plumbing in structure? G Yes UNO
O Sewer Name of Sewer System If yes:
Using an existing on-site septic system will require a current Please submit a complet d 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 Signature
Dat
Official use only
De artmental Review Approved I Denied Notes
Water Adequacy
On-site Sewage System Lr/
Tenant Review
Revision
Revised 1 1 P17/09
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AUG 1 Zpt
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