HomeMy WebLinkAboutBLD2013-01106 - BLD CD Environmental Health Review - 12/23/2013 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official) use onl�sy,
415 N. 6th Street Permit Number: V �I /'641 d
PO Box 1666
Shelton, WA 98584 Date Received: 3
Shelton: (360)427-9670, Ext. 400 Amount Received Ind.
Belfair: (360)2754467 Ext. 400
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Elma: (360)482-5269 Ext. 400 Receipt Number
Fax (360)427-7787
Applicant Information Z Ty of Review
Applicant le S Q.�x/)�C- G Date Buil ing Permit
Mailing Address 7711 C'yerl-VA, L7% 1.�'- New 0 Replacement
Ati �A� QyS y y 0 Commercial Building Permit
City State Zip O New 0 Replacement
'W36/-ySby 0 Building/Commercial Permit Revision
Daytime Phone Other Phone 0 Tenant Review
E-Mail Address zest kn'z'� 14 a'. G, 0 Pre-Application
Parcel Information
12-Digit Parcel Number /ZiO�: —9,4=06o
Site Address 7G3 ;-- hX! )r_k ^� ✓ -u y WA 6
Street Number Street Name Cny
Type of Job Net.) Z30/20 (J/ .Bc faa Please submit a scaled plot plan
Describe work s 9N'? 4icv % showing all existing and proposed
building, on-site sewage system,
Number of Bedrooms my ,. and well.
on-,S'Ite Sewage Information Water System Informations
On-Site Septic System 0 New Existing Plumbing in structure? W Yes 0 No
0 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 for both of these requirements may be on file with Mason Adequacy For
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County Public Health. Other requirements may apply_ N'f iry
Applicant Signature
Data 1 z3 r3
Official use only
Departmental Review Approved Denied Notes
Water Adequacy G LJ
On-site Sewage System W
Tenant Review
Revision
Revisetl 12MIrM