HomeMy WebLinkAboutAPPLICATION FOR EXTENSION SWG2020-00295 - SWG Application - 5/22/2023 -\\ MASON COUNTY 415 N 6TH STREET, SHELTON WA 98584
SHELTON: 360-427-9670, EXT. 400
COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
ELMA: 360-482-5269, EXT.400
/ Building Planning Environmental Health.Community Health FAX: 360 427 7798
APPLICATION FOR EXTENSION f� I�
Amount Paid: \ � `J `—' ME 71t
��.3 2U(.5' MAY0 Receipt Number:
0 2 2 2023
Instructions: Complete Parts 1 and 2. Submit application with extension permit fee. k Gheck.payaLlg 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: 60,e CCa 1, `U Phone:(. °0)490 55 65
Mailing Address of Applicant: 5 710 S E Pcvca.3;et KA
City: C1net CV State: A Zip: gs-
12-digit Tax Parcel Number: 2202 L - G-0 - -1 Q q/04
Site Address: S ZD $ 3 E. L--� vv �� �� e 14-6 vt LeA q g g 4
Permit Number: SWG 2 0 2 0_ 002
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION.
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PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied
Extension Approved New Expiration Date:
Comments:
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Environmental Health Specialist Signature: `"Th.r"'
This form may be scanned and available for public view on the Mason County Web site.
Revised: 12/13/2019