HomeMy WebLinkAboutCOM2013-00013 Asphalt Plant - EH Environmental Healh COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use o
nly
415 N. 6th Street Permit Number:
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 nformat'on Type of Review
Applican to 5 ❑ BuuiiildingPermit oReplacement
M 'ling Ad as
o mercia Budding Permit
New �' Replacement
c3 Cict � tale 4 Zip
6aneP�on�e ll� O erone , 5� t� ❑ Building/Commercial Permit Revision
Cl Tenant Review
E-Mail Address ❑ Pre-Application
Parcel Information
12-Digit Parcel Number I I U
Site Address �� Cit
Street Number Street Name y
Type of Job Please submit a scaled plot plan
L I � '4I+ showing all existing and proposed
Describe work r building, on-site sewage system,
Number of Bedrooms _ and well.
On-Site Sewage Information Water System Information
❑ On-Site Septic System ❑ New ❑ Existing Plumbing in structure? ❑ Yes ❑ No
❑ 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.
Applicant Signature
Date
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System
Tenant Review
Revision
Revised 12/17/09