HomeMy WebLinkAboutCOM2012-00011 - BLD CD Environmental Health Review - 2/8/2012 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 LT7 -
Belfair: (360) 275-4467 Ext. 400 --
Elma: (360)482-5269 Ext. 400 Receipt Number
Fax (360) 427-7787
Applicant Information Type of Review
Applicant N I�Y Date 0 Building Permit
Mailing Address 6
"5 L') E I
� 3� �I 0 New 0 Replacement
I � W i� yg 5 y �I 0 Commercial Building Permit
O New 0 Replacement
City State Zip
0 Building/Commercial Permit Revision
Daytime Phone 4kL)-135 3 Other Phone tl ib 05-7`I Tenant Review
E-Mail Address cfvwb.' 0 Pre-Application
Parcel Information
12-Digit Parcel Number
Site Address 9Se il C 54-c;_fz TZi 3 SDI Ili}c,�; y
Street Number Street Name City
Type of Job Please submit a scaled plot plan
Describe work �h '�,� f showing all existing and proposed
building, on-site sewage system,
Number of Bedrooms' Ll / and well.
On-Site Sewage Information Water System Information
0 On-Site Septic System 0 New 0 Existing Plumbing in structure? O Yes XNo
0 Sewer Name of Sewer System Porgy FIA 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 2 -6- 2-0 17
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System Z
Tenant Review
Revision
Revised 12/17/09