HomeMy WebLinkAboutCOM2012-00007 - BLD CD Environmental Health Review - 1/27/2012 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
jL C. cc-�0 Official use only
Mason County Public Health
415 N. 6th Street Permit Number:
f,T 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 Type of Review
Applicant crea�" . C 1t hhmm Date l 27 0 Building Permit
13 New 0 Replacement
U
M lli g Address k
nion Xf Commercial Building Permit X1
City State Zip
0 New O Replacement W
'�� � Building/Commercial Permit Revision
Daytte PF - �QAther Phone O Tenant Review
E-Mail Address O Pre-Application
Parcel Information
12-Digit Parcel Number
be �r '( 42 _21 —CB) I I
Site Address ��vl ue E 'S�Rs�� " (?-' --:7) 1 � h�PY17�
Street Number Street Name f 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 InformationG y r System information
0 On-Site Septic System 0 New O Existirl;W*'�l fPCmbing in structure? X Yes 0 No
O 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.pther requirements may apply.
Applicant Sign r
Date 1 " Z41
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System tZ
Tenant Review
Revision
Revised 12/17/09
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