HomeMy WebLinkAboutCOM2024-00160 - COM CD Environmental Health Review - 12/15/2014 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health COM Official use only
415 N.6ih Street Permit Number:
PO Box 1666
Shelton,WA 98584 Date Received: 1
Shelton: (360)427-9670, Ext.400 Amount Received
Belfair. (360)275-4467 Ext.400
Elms: (360)482-5269 Ext.400 Receipt Number
Fax (360)427-7787
Applicant information rW j�� A6 rd-at' Type of Review
Applicant Date la ZZ ❑ Building Permit
Mailing Addre s ❑ New ❑ Replacement
❑ Commercial Building Permit
City State Zip ❑ New ❑ Replacement
Daytime Phone Other Phone ❑ Building/Commercial Permit Revision
Tenant Review
E-Mail Address ❑ Pre-Application
Parcel Information
12-Digit Parcel Number 12 !j --NN 0001 C)
Sire Address Z3730 ! rriklF
Sala Number bum Name rm
Type of Job Please submit a scaled plot plan
Describe work C041(b E tO 0 u^A\af�WD OS� C1�o^y showing all existing and proposed
building, on-site sewage system,
Number of Bedrooms and well.
On-Site Sewage Information Water System Information
❑ On-Site Septic System ❑ New ❑r�E�xisting Plumbing in structure? ,(Yes ❑ No
ASewer Name of Sewer System QE4a3g— If yes:
Using an existing on-srle 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. her requirements may apply.
Applicant Signature
Date
Official use only APPROVE
R PUBLIC HrEDT
De artmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System
Tenant Review
Revision