HomeMy WebLinkAboutBLD2011-00369 - BLD CD Environmental Health Review - 5/10/2024 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use onI�r M'
415 N.6th Street Permit Number: R)l3) -l.lc-
PO Box 1666
Shelton,WA 98584 Date Received: S-I O -11
Shelton: (360)427-9670, Ext.400
Belfair: (360)275-4467 Ext.400 Amount Received [os 0y0�-�
Elms: (360)482-5269 Ext.400 Receipt Number 512CJ11
Fax (360)427-7787
Applicant Information Type of Review
Applicant rY<<o 3hlek Pr W4-ue5 Date `, -16-II ❑ Building Permit
Mailing Address bm' Ilpq sekki✓ WPC 17 New 0 Replacement
ur29 ❑ Commercial Building Permit
City State Zip 0 New u Replacement
Daytime Phone3baa1 549Dther Phone 205-422Z ❑ Building/Commercial Permit Revision
❑ Tenant Review
E-Mail Address 'fdN ❑ Pre-Application
Parcel Information
12-Digit Parcel Number 11W C0 IHOOO 50
Site Address 211-LpO SR• KP,lAztf-
Street Number Street ame City
Type of Job � �� � Please submit a scaled plot plan
Describe work L giq�l-- 44yu.Vf showing all existing and proposed
Number of Bedrooms 5 building, on-site sewage system,
and well.
On-Site Sewage Information Water System Information
❑ On-Site Septic System ❑ New Or Existing Plumbing in structure? PrYes ❑ No
❑ Sewer Name of Sewer System If yes:
Using an existing on-site septic system will require a current Please submit a completed Water
maintenance report and a Record Drawing (Asbuilt). Documents Adequacy Form.
for both of these requirements may be on file with Mason
County Public Health. Other requirements may apply.
Appli n Ignature
Date 5 10 I
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System ) l
Tenant Review
Revision
ReNsetl 1VI7109