HomeMy WebLinkAboutSLP2011-00006 - SPL Application - 7/11/2011 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number: -5PL2,GI i
PO Box 1666
Shelton,WA 98584 Date Received:
Shelton:(360)427-9670, Ext.400 Amount Received
Belfaic (360)275-4467 Ext.400
Elma: (360)482-5269 Ext.400 Receipt Number
Fax (360)427-7787
Applicant Information T e of Review
Applicant Datel t wilding Permit
❑ New ❑ Replacement
Mailing Address
❑ Commercial Building Permit
Cit �c�
State Zip ❑ New ❑ Replacement
UU ,,��ryry�� ❑ Building/Commercial Permit Revision
Daytime one�-�S�LVuner Phone ❑ Tenant Review
E-Mail Address ❑ Pre-Application
Parcel Information
12-Digit Parcel Num era
Site Address v4nn NON
Street Number Street Name city
Type of Job Please submit a scaled plot plan
showing all existing and proposed
Describe work building, on sewage system,ay cz�
Number of Bedrooms and well.
On-Site Sewage Information Water System Information
❑ On-Site Septic System ❑ New ❑ Existing Plumbing in structure? ❑ Yes ❑ No
1K Sewer Name of Sewer System b6 ��— 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.
A p " a t re
ate
Official use only
Departmental Review A roved Denied Notes
Water Adequacy
On-site Sewage System
Tenant Review
Revision
Revised 12/17/09