HomeMy WebLinkAboutcom2012-00027 - BLD CD Environmental Health Review - 3/23/2012 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number: Com Jz
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/P^V"/'Vn""- 4' . /�c�✓r!r?�d° Date O Building Permit
Mailing Address "ZPG /3"x Ski' O New O Replacement
�4,4,'//✓ 5 �,J--Z'le 13 Commercial Building Permit
City State Zip
0 New O Replacement
3�u �3/Sfy3 3�u ;7-7.t'/3S6 O Building/Commercial Permit Revision
Daytime Phone Other Phone p Tenant Review
E-Mail Add ress/2�a NAY ���✓I?rXd°"� SS® y/'NQOo
O Pre-Application
Parcel Information
12-Digit Parcel Number % Z Z 3 02 0 0 y
Site Address �6J-�0 znnAxT ST/✓wy
Street Number Street Name City
Type of Job rSjr-yscai%r Please submit a scaled plot plan
am`"/ c �� gvr�r✓�we showing all existing and proposed
Describe work y
v/ems Tu���� building, on-site sewage system,
Number of Bedrooms s'Y and well.
On-Site Sewage Information Water System Information
O On-Site Septic System 0 New 14 Existing Plumbing in structure? JO Yes O 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. Other requirements may apply.
Applica Si nat? _
�f Date
Official use only
Departmental Review Approved I Denied Notes
Water Adequacy f'gk w I
On-site Sewage System IL
Tenant Review
Revision
Revised 12/17/09