HomeMy WebLinkAboutCOM2014-00073 - COM CD Environmental Health Review COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
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Mason County Public Health
415 N. 6th Street Permit Number:
PO Box 1666
Shelton, WA 98584 Date Received:
Shelton. (360)427-9670, Ext, 400
Belfair: (360) 275-4467 Ext. 400 Amount Received
Elma: (360)482-5269 EM, 400 Receipt Number
Fax (360)427-7787 P
Applicant Information Type of Review
Applicant )A Daten,_ZVj_k ❑ Building Permit
iling Address (�r'> ¢r,.r �- S— ❑ New ❑ Replacement
�7— l 4 Glut ❑ Commercial Building Permit
City State Zip
❑ New ❑ Replacement
Z��qf� ❑ Building/Commercial Permit Revision
Daytime Phon Other Phone Tenant Review
E-Mail Address j s h Q gil I• ,con I Pre-Application
Parcel Information /
12-Digit Parcel Number
Site Address -)rVr>(' l_ 1i at a r LEA
Street Number Street Name City
Type of Job Please submit a scaled plot plan
Describe work (Au. y Esenso &S&' ewe-. showing all existing and proposed
Number of Bedrooms- building, on-site sewage system,
� and well.
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.
-Applicaryt Signat re
Date 67-24. 4j
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
Mason County DeptHeallin
On-site Sewage System
Tenant Review
Revision _I
Revised 12/17/09
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Initial Suryer (Y/N): Y
Area: 5 Union R>Sy06 Name: ERNEST R & PATRICIA B HUGHES
Over Title: Mr Owner FN.: Ernie Owner LName/C0: Hughes
Owner Address: 3291 Carryon Terrace
Owner City: Laughlin rimer State: NV Owner Zip: 89029
Owner Phone: Mork Phone:
Parcel #: IZ309-42-DD240 LUC: 1114 LUOD: Four Bed
Site Address: NE 3281 Old Belfair Hwy
Site City: Belfair Site State: NA Site Zip:
Building Type: F
Yr Last Pumped:
Occ Title: Occ FNeme: Occ LName/C0:
Occupant Phone:
Info on Water Cormery (Y/N):
Would like workshop (Y/M):
Permission to Insp. (Y/N): Y
e Comments:
i Initials: GADS Level 1 Insp (MoDaYr): 8/22/94
Level 1 Completed (MoDaYr): 8/22194 Level 2 Insp (KWaYr):
1 Prosecutor referral (MoDBYr): System Type: S
Install Date: U Classification (P,F,L,PF,S): F
FAILURE PRIORITY (1,2,3,4,5): 3 Shoreline (Y/N): N
Completed! (Y/W): I Caipletion Date (NWaYr): 8122/94
Observations: Broken greywater discharge, old tiles plugged,
ron-permitted repair. Greywater discharge to surface of grand.
Letter (MolaYr):
ENVIRONMENTAL 9/16 HEALTH INFO:
Data to EH (Wayr): 9/16/94 Received by: 1AL
11/
I LDa[e (MaDaYr): 9/16/94 ELDATE (MoDaYr): fl/1/94
Action date for contact (No[mYr):
Action cement: Repair completed.
Permit/Plan Received (MWAYr): 4/5/95 Permit Number: SWG95-
Design Received (MoDaYr): 7/14/95Repair Completion (MoDaYr): 7/27/95
Repair System Type: Greywater system, see repair cements.
Repair Comments: Repair was done with no permit and no Helath
Dept. Ion (samw:nt. Omer got permit and a L2 designer submitted an "As Built".
Letter #1 (mmddyy): 12/13/94
Letter #2 (mmddyy):
Site visit/Phan: calls (mmddYy):
Certified Letter #3 (nnddyy):