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HomeMy WebLinkAboutSWG2022-00190 APPPLICATION FOR EXTENSION - SWG Application - 9/5/2023 m� `� 415 N 6TH STREET, SHELTON WA 98584 c. \, MASON COUNTY SHELTON: 360-427-9670, EXT.400 11:_ �I 1) COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT. 400 -; I/ni tv� ELMA: 360-482-5269, EXT. 400 �'8 _` `y Building,Planning,Environmental Health,Community Health FAX: 360-427-7798 APPLICATION FOR EXTENSION I r 4G Amount Paid: 1, (DO O . - SEA Receipt Number: a3 — �41 -4 R 0 S?0?� fee. Make che /k�•. able o Instructions: Complete Parts 1 and 2. Submit application with extension permit y Mason County Treasurer. Staff will review your application and determine if the extension can be app • - -. 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 Q' Name of Applicant: /( )<q CGS eefv4 Phone: YO 2 SSU ` 7633 Mailing Address of Applicant: 500 g tJof ff t'1 Li cods ©r City: P(0S/2eClt State: ?, / Zip: `f 005 12-digit Tax Parcel Number: 3733 ( 33 Qo Z- I for 5ff. IoCQ 0� a Y F9 ���, la j Site Address: - Permit Number: SWG S�6 ZO Z� —OG 170 PART 2: EXPLAIN WHY/ YOUQ NEED AN EXTENSION., y� ,off /,/,,/�t- 0/\ i*CL (i' c3 tivrYh (ii ;'? and [. ,/c(bI/ ly eq1p1 PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only) DMELINT 0 Extension Denied (�/ �/ EP 0 5 2023 ?6Extension Approved New Expiration Date: I 1 Comments: 11 LYw--- Environmental Health Specialist Signature: This form may be scanned and available for pu c view on the Mason County Web site. Revised: 12/13/2019