HomeMy WebLinkAboutBLD2014-00434 - BLD CD Environmental Health Review - 5/15/2014 lkl_://; k�511o, 4-
ENVIRONMENTAL HEALTH REVIEW FOR COMMUNITY DEVELOPMENT
Mason County Public Health =R"e'ved
icial Beu only .
415 N. 6th Street I H �
PO Box 1666
Shelton,WA 98584 n/�,/I� 1Shelton: (360)427-9670, Ext. 400 ed �ChJBelfair: (360)275-4467 Ext.4006U ��aElma: (360)482-5269 Ext.400 r V/CYv-�/�?Fax (360)427-7787Applicant Information oType oevw
Applicant )�ky�r� > + " Date5�I ■ Building Permit (commercial orresidential)
Mailing Address <� F 1 0� ^�� Dr 0 New ■ Replacement
151 /7 irl lC2JR`l 0 Remodel 0 Revision
city State Zip O Tenant Review
Daytime Phone`/ D-/o3a30ther Phone O Pre-Application
E-Mail Address
Parcel Information
12-Digit Parcel Number 3�a3 y 3'OOFI I D a oo as 0
SiteAddreSSR330 S3 korY�i /Ofa O)TTS A111.5 /)14Irr✓2-
Street Number Street Name Olt'
Type of Job Please submit a scaled plot plan
.^� �l f showing all existing and proposed
Describe work ,A Oar building, on-site sewage system,
Existing Bedrooms O P_ro posed edrooms and well. Max Size 11"x17".
On-Site Sewage Information Water System Information
■ On-Site Septic System 0 New ® Existing Plumbing in structure? ■ 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 Adequacy Form.
for both of these requirements may be on file with Mason
County Public Health. Other requirements may apply.
Applicant Sig ture
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#'s
Water Adequacy pC 3�{ r� 1L
On-site Sewage System LE GJ 2 t�1b-JtI `
Tenant Review
Revision
Revised IIIOJ2014