HomeMy WebLinkAboutBLD Water Adequacy - 11/18/2011 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use onl
415 N. 6th Street
PO Box 1666 Permit Number:
Shelton, WA 98584 Date Received: n^ `
Shelton: (360) 427-9670, Ext. 400 Amount Received S
Belfair: (360) 275-4467 Ext. 400 '
Elma: (360) 482-5269 Ext. 400 Receipt Number �1J
Fax (360) 427-7787
Applicant Information Type of Review
1
Applicant LA-41 N OJ&Y-L_ Date -ISAI 10 Building Permit
Mailin Addres 9-4. '3 )I New 13 Replacement
13 Commercial Building Permit
City State Zip 13 New 0 Replacement
�� 13 Building/Commercial Permit Revision
Daytime Phone Other Phone p Tenant Review
E-Mail Address p Pre-Application
Parcel Information
12-Digit Parcel Number ZZ) -- 0 1 1
Site Address , Q Ir1
Street Number Street Name City
Type of Job Please submit a scaled plot plan
Describe work 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 'New 13 Existing Plumbing in structure? *Yes 0 No
0 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 a y
County Public Health. Other requireme is may apply.
Applica natur
— - &_/ , — /
— " Date
Official use only
Departmental Review Approved Denied Notes
Water Adequacy 12 I1 1 11
On-site Sewage System
Tenant Review
Revision
Revised 12/17/09
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