HomeMy WebLinkAboutSWG2017-00280 APPLICATION FOR EXTENSION - SWG Application - 6/5/2020 6TH STREET,SHELTON MASON„COUNTY 415 NSHE TON:360-427-9670 WA 98584
OCOMMUNITY SERVICES BELFAIR:360-275-4467,EXT.400
ELMA:360-482-5269,EXT.400
Budding,Manning,Environmental Health,Community Health FAX:360-427-7798
APPLICATION FOR EXTENSION 2CCICE if E
Amount Paid: 1 4G- 111 JUN 052020
Receipt Number: cO &
Instructions: Complete Parts 1 and 2. Submit application with extension permit fee. Make check payable to
Mason County Treasurer. .Staff will review your application and determine if the extension can be approved. If
approved,the permit may be extended for up to one additional year from the original expiration date.
Extensions must be applied for prior to original expiration date. Multiple extensions on a single permit
will not be approved(one per design/permit).
PART 1: APPLICANT AND PARCEL INFORMATION
Name of Applicant: 1_.)Q� :]fin% h Phone:
Mailing Address of Applicant: I L bb e. S Or Lea.)
tn�r.City:________________________State:
t W A Zip:`
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12-digit Tax Parcel Number: 2L', Z Cx7 1 4
Site Address: tr-�1C2 ci �5Ce
Permit Number: SWG Ol Z '- On BO
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION.
PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only)
0 Extension Denied
d3-fxtension Approved New Expiration Date: ;r- V1 '?O? I
Comments:
Environmental Health Specialist Signature:This form may be scanned and available for public view on the Mason County Web site.
Revised: 12/13/2019