HomeMy WebLinkAboutSWG2020-00317 APPLICATION FOR EXTENSION - SWG Application - 7/11/2023 MASON SON COUNTY 415 N 6TH STREET, SHELTON WA 98584
ivil� COUNTY 1 SHELTON: 360-427-9670, EXT.400
III"F COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT. 400
ELMA: 360-482-5269, EXT. 400
/ Building, Environmental Health,Community Health FAX: 360-427-7798
APPLICATION FOR TENSION Ir, , — ..-
6OAmount Pain: ,/„.." s'
Receipt Number:-
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Instructions: Complete Pads 1 and 2. Submit application with extension permit fee. Make efteck-payat�la,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 AARC L INFORMATION
Name of Applicant: I ! yv10-k- 1 ✓V tvAer Opt) Phone: . , 7
Mailing Address of Applicant: A a E C� C 6"lBc..1.gal \, ,r--- i
City: Se_Nix, .[-- State: W —- Zip: C")(55,71\1101k
12-digit Tax Parcel Number: [ �0 77 j9,l)
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Site Address: 7 1 �, l/;IL I'C L 4Q C . E e_1Vkt,,t C3` ?8,5
Permit Number: SWG i ' _ .O c 31 7
PART 2: EXPLAIN W/HY YOU NEED AN EXk'ENSION. acxyotviA
c-t_t'\ t vv,t CA' CL_ \ ANAC ..(-3,_
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PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only)
LI Extension Denied
yExtension Approved New Expiration Date: 7 0 "`�
Comments:
Environmental Health Specialist Signature:C/ i a o k 4LWTh
This form may be scanned and available •r pub c view on the Mason County Web site.
Revised: 12/13/2019