HomeMy WebLinkAboutCOM2016-00128 - COM Application - 10/3/2016 ► ENVIRONMENTAL
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MASON COUNTY HEALTH
cot, (360)427-9670 Shelton ext.352
DEPARTMENT OF COMMUNITY SERVICES (360) 275-4467 Belfair ext. 352
BUILDING•PLANNING•FIRE MARSH (360) 482-5269 Elma ext. 352
RECEIVED
Mason County Bldg. 8
�ssa 615 W. Alder Street, Shelton, WA 98584 OCT 9 3 20116 www.co.mason.wa.us
615 VV, �; ; �.,_.w COM Zy Ib -001Z16
CHANGE IN TENANT APPLICATION
PROPERTY INFORMATION
Date: ZU ( Assessor's Parcel Number:
Legal Description:
Building Site Address: f ;
APPLICANT INFORMATION
Name of Applicant:
Mailing address: 1 n Q C4
City: •t< State: Zip: 9,C_!5 S 9,-c4
Day phone: Contact Person:,); " T (Tr Message phone:,3E,,,C s I
PROJECT INFORMATION
P ��Ct G Ct C r &S rc5
Proposed business name: �
Proposed use: VC) t'eSSa Number of employees:
Previous business name: Describe previous use: E
STRUCTURE DETAILS
Check one: O Detached single level/ single tenant 0 Single level/ multi tenant
O Multi level/single tenant O Multi level/multi tenant
Age of structure: Is structure curr ntly If not occupied, how long has it been vacant?
occupied? es No Yr. Mo.
Square Basement: it Mezzanine: Second Third:
footage: ? ,�
Is the structure Type of Heat: Circle one: Furnace Heat Pump "Electric wall",` Radiant
heated?
Circle one:('Yes) No Fuel type: Circle one: t"Electric 1 Liquid Propane Natural Gas Oil
-�(IVill there any changes to the fol"lowi g? ircle yes or no, if applicable:
Floor lay-out: Yes No Lighting: Yes o Heating: Yes
Exterior Finishes: Yes o Interior Finishes: Yes No_ Parking: Yes ;- Nol
Number of restrooms prove ed: Number of fixtures in eacl'
--Water Closets II Lavatories— Bath/Shower
Is structure handicap accessible? Entry: (Yes) No Restroom(s): Yes;No"
Is the structure equipped with a fire sprinkler system? Yes o Fire alarm system? Yes ✓No"N
Monitoring Station Name: Phone number:
APPLICATION WILL NOT BE ACCEPTED WITHOUT:
Floor Plan (5 sets):
• Draw the floor plan to scale • Use of rooms
• Room Dimensions • Location of all exits and windows (include dimensions,
• Location of plumbing and mechanical fixtures counters, tables, shelving, benches, fire exits
• Interior doors with swing radius and exit signs).
Site Plan (1): Note scale used
• Property lines, easements, & right of ways • Location of all existing structures & dimensions
• Distance, in feet, from property line & structures • Location of all existing structures & dimensions
• On-site sewage tanks and drain fields, & reserve • Landscape buffer yards
• Location of fire hydrants &vehicle access roads • Well location
• Parking areas (number & arrangement)
Continued on back
A, T
MASON COUNTY PUBLIC HEALTH D fv OFFICIAL USE ONLY
ate rece
COMMUNITY DEVELOPMENT �D 3 12,0 IIo
ENVIRONMENTAL HEALTH REVIEW A�uOnt reOceived� Rece' ed by:
415 N.6th Street Shelton,WA 98584
Case number:
(360)427-9670,Ext.400 (360)275-4467,Ext.400 to 11_DD
1.Applicant/Property Information
Appiicant Name Assessors Parcel Number
'� 9,,t 2- as -66 t 46
Mailing Address- Street City State Zip
Site Address- Street City
She �i
Contact Person I Contact P ne Contact Email
Cl _ -L� i c ' } � t
2.Type of Review/Job 3.Job/Site Information
Check all that apply
❑ Residential ❑ Commercial XTennant Review
❑ New ❑ Replacement ❑ Pre-Application + _
Existing Number Proposed Additional Total Bedrooms
❑ Remodel ❑ Addition ❑ Other(explain below) Bedrooms Bedrooms
Describe Work Use for remodels,additions,or replacements
Existing Sq.Ft. Proposed Sq.Ft. Total Sq.Ft.
Basement?(yes or no) Total Number of Floors
Interior Remodels need to attach an Existing Floor Plan and Proposed Floor Plan
with room designations.Max Paper size 11x17. Property on Shoreline(yes or no)
4.On-Site Sewage System/Sewer Information
Perimeter Drains Proposed?(yes or no)
Property Served By:
)'On-Site Septic System ❑ New Existing Number of Employees(if applicable)
❑ Sewer ❑ New ❑ Existing
S.Water Source Information
Permit No.(if applicable) Plumbing in structure? Yes ❑ NO
Name of Sewer System(if applicable) If yes:
Using an existing on-site septic system will require a current maintenance report Please submit a completed Water Adequacy Form.
and a Record Drawing(Asbuilt). Documents for both of these requirements may An incomplete submitted Water Adequacy Form may be
be on file with Mason County Public Health.Other requirements may apply. returned,and hold up review process.
Site Plan
A scaled Site Plan is required with all permits,except interior remodels. An incomplete submitted site plan may be returned,and
hold up review process. Paper size for site plan can be 8.5x11,8.5x14,or 11 x17(max). Please use checklist below:
❑Property lines/dimensions ❑Primary Drainfield area ❑Reserve Drainfield area ❑Existing/proposed wells ❑Waterlines
❑Septic Tanks location ❑Location of curtain/perimeter drains ❑Direction of Slope ❑Driveways/Parking areas/Easements
❑Existing Structures/buildings ❑Proposed Structures/Buildings ❑Sewer lines/tanks ❑Additions ❑North Arrow ❑Scale Bar
Applicant Signature K ( Date /0— j-
Official use only
Departmental Review Approval Intis. Date Notes,Conditions,Related Permits
Water Adequacy
Sewer/Septic System
Tenant Review
Revision
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE Revis // 15
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Drain system for sink.
Sink drain leads to first barrel.When filled close to the entrance point, an automatic switch turns a
pump on to pump it into second barrel. The second barrel is used to transport to the dumpsite.The
gray water is dumped in the Shelton city sewer system. The dump site is located at: 1927 Ferry St.
Shelton,WA 98584.
Public Water system: Hidden Haven WFI#: 32660j