HomeMy WebLinkAboutAPPLICATION FOR EXTENSION SWG2019-00128 - SWG Application - 5/22/2022 • 415 N 6TH STREET, SHELTON WA 98584
MASON COUNTY SHELTON: 360-427-9670, EXT.400
COMMUNITY.11" 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
Amount Paid: be U4o6 . -
Receipt Number: "): -
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: au / W. 9y' U icerl e J, .6 a: la-7 Phone: 36•0 73( 3 6-6 SJ
Mailing Address of Applicant: .5-'7( - 15%3' g d
City: 5 �J/-;14 State: Zip:f`$�S�f
12-digit Tax Parcel Number: 7,�(.) O7h 0 / `70
Site Address: 5`7( & SkoohLern /-?ci .Stioiti y tea , 7;7
Permit Number: SWG —0O /Z '
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION.
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PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only) pp n
Extension Denied U `I [?
MAY 222
ID Extension Approved New Expiration Date:
23
Comments: . Pau S 8�� to/ yr �lOZ2
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Environmental Health Specialist Signature:
This form may be scanned and available for public view on the Mason County Web site.
Revised: 12/13/2019