HomeMy WebLinkAboutBLD2012-00174 - BLD CD Environmental Health Review - 3/29/2012 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number: fJ-.P l 2---001-14
PO Box 1666 12-
Shelton, WA 98584 Date Received: 1 Pv3L —
i
Shelton: (360) 427-9670, Ext. 400 Amount Received •0 p
Belfair: (360) 275-4467 Ext. 400 /
Elma: (360) 482-5269 Ext. 400 Receipt Number Dl5-/41121
Fax (360) 427-7787
Applicant ormation / Type of Review
Applicant v�o SSf� Dater? �'//Z 10 Building Permit
Mailing Address ZZ c( y )F New O Replacement
0 Commercial Building Permit
City State 44-f Zip /S�/ 0 New 0 Replacement
O Building/Commercial Permit Revision
Daytime Phone. ther Phonef?ao7 5/74 O Tenant Review
E-Mail Address 4aR'W'& d(( d � O Pre-Application
Parcel Information
12-Digit Parcel Number 3 Z-z3Le _ 3 1 ` 000 S Z
Site Address '�& 5a rle�&
Street Number Street Name City
Type of Job ��yy nn DD _ Please submit a scaled plot plan
Describe work showing showing all existing and proposed
building, on-site sewage system,
Number of Bedrooms CL and well.
On-Site Sewage Information � Water System Information
0 On-Site Septic System 0 New "Existing Plumbing in structure? 0 Yes 0-M
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. Other requirements may apply.
Apt nt Signature
Date
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System i
Tenant Review
Revision
Revised 12/17/09
ENVIRONMENTAL
HEALTH
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