HomeMy WebLinkAboutBLD2012-00150 - BLD CD Environmental Health Review - 3/25/2012 � Cc� � tt `cC
COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number: IC1oZDl'ol
PO Box 1666
Shelton, WA 98584 Date Received:
Shelton: (360)427-9670, Ext. 400
Belfair: (360) 275-4467 Ext. 400 Amount Received
Elma: (360)482-5269 Ext. 400 Receipt Number
Fax (360)427-7787
Applicant Information // Type of Review
Applicant_ Tod L,,w /C �� _ Date_3�/Jl Z P Building Permit
Mailing Address_ s, _ I New 0 Replacement
&VIL-el _ ��q q 8/q� 0 Commercial Building Permit
City State Zip 0 New 0 Replacement
Z06 0 Building/Commercial Permit Revision
Daytime Phone 6ro-L0} Other Phone
� Tenant Review
E-Mail Address p Pre-Application
Parcel Information
12-Digit Parcel Number a ZD z_G 10 y b 08 ,
Site Address__S�v E. IJk L " , ____ —_ _—S4O
Street Number Street Name City
Type of Job / Please submit a scaled plot plan
Describe work_le O showing all existing and proposed
-- building, on-site sewage system,
Number of Bedrooms and well.
On-Site Sewage Information Water System Information
16 On-Site Septic System O New Existing Plumbing in structure? JX 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
for both of these requirements may be on file with Mason Adequacy Form.
County Public Health. Other requirements may apply.
Appli iP Si�pat}yre1A
,L l/u/�i-`_� Date —_--
Official use only
Departmental Review Approved I Denied Notes
Water Adequacy 4 & 12_
On-site Sewage System 1F (o 11 L
Tenant Review
Revision
Revised 12/17/09