HomeMy WebLinkAboutCOM2016-00048 - COM CD Environmental Health Review - 4/5/2016 (2) COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health ��
415 N.6th Street Permit Number.
PO Box 1666 -
Shelton,WA 98584 Date Received:
Shelton: (360)427-9670, Ext.400 - -
Beltair.(360)2754467 Ext.-400 Amount Received
Elms: (360)4825269 Ext. 400 ,^,,tt9��,t
Fax (360)427-7787 Receipt Number
Applicant In onnation Type of Review
Applicant Datel(Q Cl Building Permit
O New O Replacement
Mailing Addrea
O Commercial Building Permit
q State Zip 17 New 0 Replacement
City Ph 52 Other Phone O Building/Commercial Permit Revision
DaWienant Review
E-Mail Address 0 Pre-Application
Parcel Information
12-Digit Parcel Number — Z
Site Address /S/ E—Y;s d -10 Su1TtaB t�FL iY!
Street Number Street Name Oity
Tye of Job Please submit a scaled plot plan
Describe work�.c-�.�� U��- ' showing allexisting s and proposed
building, on-site sewage system,
Number of Bedrooms .er� and well.
On-Site Sewage Information Water System Information
0 On-Site Septic System 0 New 0(Existing Plumbing in structure? *Yes 0 No
Sewer Name of Sewer System I Tiu4.'5au_IV If yes:
Using an existing on-site septic system will require a current Please submit a completed Water
maintenance report and it Record Drawing (Asbuilt). Documents Adequacy Form.
for both of these requirements may be on file with Mason
County Public Health. Other requirements may apply.
Appl ant Sig nagye
Date
Official use only
Departmental Review A roved Notes APFROVED
vie
Water Adequacy
On-site Sewage System
Tenant Review
Revision
Revised 12/17/09