HomeMy WebLinkAboutCOM2011-00104 - BLD CD Environmental Health Review COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official
�use
(only r— I
415 N. 6th Street Permit Number 1 V`d�1"L-- . �I" I
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
Applicar0 pp�1�� UC6 Date 0 Building Permit
Mailing Address o New o Replacement
1 ( HC) EQGjRO), �q Commercial Building Permit
,,�IIIyy State Zip Xil New 0 Replacement
yt, �Id'b � 13 Building/Commercial Permit Revision
Da line h n � er Phone
O Tenant Review
E-Mail Address O Pre-Application
Parcel Information 2
12-Digit Parcel Number o��Jo� —�7C� — L
Site Address eg 37 I�,16 St Q�f" 3 22C V'\
Street Number Street Name City
Type of Job Please submit a scaled plot plan
Describe work 2AP V-Q� showing all existing and proposed
Number of Bedrooms building, on-site sewage system,
and well.
On-Site Sewage Information Water System Information
0 On-Site Septic System 0 New O Existing Plumbing in structure? Yes 0 No
Sewer Name of Sewer System V' If yes:
Using an existing on-site septic system will re nt 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
Official use only
Departmental Review Approved Denied Notes
Water Adequacy 15 Z
On-site Sewage System
Tenant Review
Revision
Revised 12/17/09