HomeMy WebLinkAboutBLD2014-00434 - BLD CD Environmental Health Review - 5/15/2014 (2) ENVIRONMENTAL HEALTH REVIEW FOR COMMUNITY DEVELOPMENT
Mason County Public Health Official use o I y� 1
415 N. 6th Street Permit Number:
PO Box 1666 +
Shelton,WA 98584 Date Received: l� I'
Shelton: (360)427-9670, Ext. 400 Amount Received L�
Belfair. (360)275-4467 Ext. 400
Elma: (360)482-5269 Ext.400 Receipt Number V/CJ4-Nxt
Fax (360)427-7787
Applicant Information y Type of Review
Appllcant�„p��' fJ�P�U �I+ 1` Date L7 ■ Building Permit (commercial or residential)
Mailing Address S�o I Gi] jt 2 D�n �r O New ■ Replacement
c[vj L_ 0 n
.1 ___�IP�SS3 O Remodel O Revision
City State Zip p Tenant Review
Daytime Phone`/ -&�ZAther Phone O Pre-Application
E-Mail Address
Parcel Information
12-Digit Parcel Number 3,�a3 y�3 ooa 10 a as
Site Address n w
n,_ .. j Rodfr 166 UN11S f}N `3 ��1� 16Y
Street Number Street Name City
Type of Job Please submit a scaled plot plan
:ed
� ' showing all existing and proposed
Describe work / building, on-site sewage system,
Existing Bedrooms Propo edrooms and well. Max Size 11"x17".
On-Site Sewage Information Water System Information
■ On-Site Septic System ❑ New ■ Existing Plumbing in structure? ■ Yes ❑ No
O 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.
Applicant Sig It
Date ,
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE
Official use only
Departmental Review Ap roved Date Notes, Conditions, Related Permit#'a
Water Adequacy of J5{ d' K_
On-site Sewage System F !I WwJt/ rr
Tenant Review
Revision
Revisetl 1/10/2014