HomeMy WebLinkAboutPAR2017-00004 - PAR Application - 1/25/2017 (3) / COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N.6th Street permit Number: Pau 17 - 0000t/
PO Box 1666
Shelton,WA 98584 Date Received: t /ZS
Shelton: (360)427-9670. Ext. 400 Amount Received Z(0 0�
Belfair. (360)275-4467 Ext 4D0
Elma: (360) 4825269 Ext. 400 Receipt Number
Fax (360)427-7787
Applicant Information Tvpe of Review
Applicant G✓/r.C/HM ,ecyq(Ooa/ Date / 2 /7 p Building Permit
Mailing Address t T180 Cawga+ Ro 0 New o Replaceslent ,f
/e,we"'at= (fA 92soy 0 Commercial Building P it
City State Zip U New D Replaceme&.
Daytime Phone, 14-.t5t-
zOther Phone 0 Building/Commercial Permit Revision
O Tenant Review
E-Mail Address CoM )if pre-Application
Parcel Information
12-Digit Parcel Number -2— 073 _ `7 Z — 0oi00
Sile Address ee 1-7 WEST W ST SR�—TOt--t
Street N..he Sheet N., Ott,
Type of Job Please submit a scaled plot plan
Describe work showing all existing and proposed
Number of Bedrooms Z building, on-site sewage system,
and well.
On-Site Sewage Information Water System Information
IQ On-Site Septic System 0 New ❑ Existing Plumbing in structure? 'PLYes 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 (Asbuift). Documents Adequacy Form.
for both of these requirements may be on file with Mason
County Public Health. Other require, is may apply.
lean
Date Date Z` -�� ZO 1
U Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System
Tenant Review
Revision