HomeMy WebLinkAboutBLD2012-00238 - BLD CD Environmental Health Review - 4/16/2012 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number: -IGI,2t71oZ -Q�3_ 8
PO Box 1666
Shelton,WA 98584 Date Received: 4 _I U .o2Q
Shelton: (360)427-9670, Ext.400 Amount Received rC72�, ,
Belfair: (360)275-4467 Ext.400
Elma: (360)482-5269 Ext. 400 Receipt Number
Fax (360)427-7787
Applicant Information Type of Review
Applicant-LIIIIIO/A Date4-I P-IZ 0 Building Permit
!� O New 0 Replacement
Mailing Address
qwnt E3 Commercial Building Permit
t� '® b 0 New O Replacement
city State ZIP
'1 0 Building/Commercial Permit Revision
Daytime Phonic"-LCAS AeOther Phone O Tenant Review
E-Mail Address 0 Pre-Application
Parcel Information
12-Digit Parcel Number Z2_00 4 — t t
Site Address � ! ��P 324101 E lS� C'e11i1m �Wlg (p
Street Number Street Name s' I av� city c1
Type of Job Please submit a scaled plot plan
Describe work S/ `� ` � , showing all existing and proposed
building, on-site sewage system,
Number of Bedrooms _ and well.
On-Site Sewage Information Water System Information
AT On-Site Septic System 0 New existing Plumbing in structure? O Yes 46 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 Adequacy Form.
for both of these requirements may be on file with Mason
C ty Public H th. Other requirements may apply.
pp i nt Sigpa r 'f
Cam/\ t Date t' t�' tZ—
Official use only
Departmental Review Approved Denied Notes
Water Adequacy /
On-site Sewage System W-2 WL
Tenant Review
Revision
Revised 12/17/09
C n pN C0rJJV
Public Health
Always worldrg for safer healthler Mason County
PO Box 1666,415 N e Street, Bldg 8,Shelton WA 98584,
Shelton: (360)427-9670 ext 400 4- Belfair: (360)275-4467 ext 400 ❖ Elma:(360)482-5269 ext 400
FAX (360)427-7787
Application for Determination of Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully completed.
2. Complete only the portion of Part 2 applying to the type of water system utilized.
3. Submit completed application,with attachments to the health department for review.
Part 1: ApplicanV Parc ldentif cation `
Name on Applicant: _ Ln1 14,2&- Date: uJ/ G Yr 2 C / L
Mailing Address: /yE 7 i{/. //fir/✓•-1,JSJ6' Phone:: 3s3 5 =66 e
Parcel Numb :: Z Z 2 V L'
Signature: C"X Date:
Type of Water System Reason for Application
Public/Community Water System (2 or more I)l<Building permit
connections)" ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement(please indicate name of water
If you have more than one residence connected system below if applicable-no signature
to this well, check the Public/Community Water required)
System box.
Part 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Public Water System
Name of Water System:�/f/n cin-+I to coey� 's�1d Civ
Water Facility Inventory(WFI) Number: /3S-7/(—
(write"none"for two-party)
JX I am the manager of this water system.The water system has been approved for_services.
There are presently connection(s) in use. This will be the _connection.
❑ 1 am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system (i.e.: recreational to full time). Please indicate on the following line the nature
of this change:
This water system is able and willing to provide water to this(these) connection(s)without exceeding
the limits of the water system or an limiits set by state and local regulation.
Signature of Water System Manager Date Il �
Revised 3/15/2012
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