HomeMy WebLinkAboutBLD2007-01857 - BLD CD Environmental Health Review COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number: 1 W 2o2-1-016>7
PO Box 1666
Shelton,WA 98584 Date Received:
Shelton: (360)427-9670, Ext. 400 Amount Received
Belfair: (360) 2754467 Ext. 400
Elma: (360)482-5269 Ext. 400 Receipt Number
Fax (360)427-8442
Applicant �rrf rmatio\\n Type of Review
Applicant 'I �r�1 Date 0 Building Permit
Mailin/g/,A//dd ss �a(' � 0 New 0 Replacement
0 Commercial Building Permit
city z��� State Zip 0 New E3 Replacement
Daytime PhoneWOther Phone 0 Building/Commercial Permit Revision
0 Tenant Review
E-Mail Address de,� 'kg' �'OL'2.C1e4--L 0 Pre-Application
Parcel Information
12-Digit Parcel Number �ZZS`?o5AZ�j 3 Z
Site Addresses
Street Num er Street Name City
Type of Job Please submit a scaled plot plan
Describe work showing all existing and proposed
Number of Bedrooms /j� building, on-site sewage system,
and well.
On-Site Sewage Information / Water System Information
* Yes Septic System 0 New H 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 Signature
Date?
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System
Tenant Review
Revision
Revised 12/17109