HomeMy WebLinkAboutBLD2015-00865 - BLD CD Environmental Health Review - 10/5/2015 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
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415 N. 6th Street Permit Number: 1A2015 J u` 8��
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 5 , 6 —cpy
Fax (360)427-7787
Applicant Information LAC Type of Review
Applicant IZO b 1 n "&\f i lkaetc, yyt,f}C Date(9 S IS Building Permit
Mailing Address P, n • 0 New IK Replacement
Lo0.cey L- A 995o443 }y 0 Commercial Building Permit
City State Zip 0 New 0 Replacement
3A00- H BS` 'Sb o -,I 84- 0 Building/Commercial Permit Revision
Daytime Phone o-I tr 5 Other Phone 11994
O Tenant Review
E-Mail Address 4-a�eY.,IQ co�,r,as4. n e-1' 0 Pre-Application
Parcel Information
12-Digit Parcel Number 32_Z 32 --SD- 9 a
6 0 o I
Site Address 7 fro F_ . Sa-o}e. (Zo—}t 1 ob Lot �9-1
Street Number Street Name City
Type of Job Please submit a scaled plot plan
Describe work showing all existing and proposed
Number of Bedrooms 1 building, on-site sewage system,
and well.
On-Site Sewage Information Water System Information
01 On-Site Septic System O New � Existing Plumbing in structure? 4 Yes 0 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
for both of these requirements may be on file with Mason Adequacy Form.
County Public Health. Other requirements may apply.
Applicant Signature (.ob j h ♦-1-,vd V i 11�a ftA 4 t_Lc_
Date I o -5- Is—
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System
Tenant Review
Revision
Revised 12/17/09
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