HomeMy WebLinkAboutPAR2011-00022 - BLD CD Environmental Health Review - 9/13/2011 08/29/2011 11:38 FAX 360 427 7798 MASON CO PERMIT CTR �J605
COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Offici 4use y415 N. 6th°Street Permit Number: 1
PO Box i9666
Shelton.WA 98564 Date Received:
Sho,,Aon: (360)4271"9670, Ext. 400 Amount Receive
Se:lfair. (360) 275-4467 Ext.400
E Ima: (360)482-5269 Ext.400 Receipt Number
_ Fax (360)41 7-8442
Applicant Information Type of Review
Applicant?UQ6J�`(P �i�t�L� Date Building Permit
Mailing Address_iGo i New A Repla rent
Commercial Building ermit
City State Zip New 0 Repla meet
• j n ' O Building/Commercial ermit Revision
Daytime PhoneyTl- � Other Phone 0 Tenant Review
E-Mail Address19 Pre-Application
Parcel Information
12-Digit Parcel Number
Site Address o
Street Number Street Name
Type of Job Please submit a scale d plot plan
Describe work-& E_ Ld�M M 14L God _ showing all existing proposed
building, on-site se wag system,
Number of Bedrooms y )ZA and well.
On-Site Sewage: Information Water System Information
0 On-Site :septic System , 13 Newt r ❑ Existing Plumbing in structure? )(Yes 0 No
14 Sewer Nai ne of Sewer System Mq'�-006) 4 Qa' 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 Signature
Date
Official use only
Departmental Review Ap roved Denied Notes
Water Adequacy
On-site Sewage System
Tenant Review
Revision
Revs ied 12M7/09