HomeMy WebLinkAboutCOM2012-00015 - COM CD Environmental Health Review - 2/22/2012 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only ' F
415 N.Sth Street Permit Number: Cn•n':): - C�C:�J
PO Box 1666
Shelton,WA 98584 Date Received: !
Shelton: (360)427-9670, Ext.400 Amount Received
Belfair: (360)275-4467 Ext. 400
Elma: (360)482-5269 Ext.400 Receipt Number
Fax (360)427-7787
Applicant Information Type of Review
Applicant GrasT or-�..1arul,,a4s1 cxc Date Z t tel 0 Building Permit
Mailing Address o o• �So1r 94-! O New 0 Replacement
aio /14msoa- u.M- gegjS 0 Commercial Building Permit
city State Zip 13 New Pr Replacement
Daytime Phone Zt3•`teja9' 0 Building/Commercial Permit Revision
`other Phone's3.85�.8S7o 0 Tenant Review
E-Mail Address CW3OeeAw)va.Q✓%sors.�M OPre-Application
Parcel Information
12-Digit Parcel Number /2f29 Ht ootao
Site Address 21 .mot s*m ?an OAX-*�
Street Number Street Name CRy
Type of Job Please submit a scaled plot plan
T�' A uc'� og•,cy 4�Era showing all existing and proposed
Describe workt
building, on-site sewage system,
Number of Bedrooms and well.
Onate Sewage Information Water System Information
0 On-Site Septic System 0 New 0 Existing Plumbing in structure? �IrYes 0 No
Rl Sewer Name of Sewer System ?&Pok o_ 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.
Appl'i�agt Signature
��/�� Date Z Lt Zw�
Official use only
Departmental Review Approved Denied Notes
Water Adequacy rW3 °J IL
On-site Sewage System
Tenant Review
Revision
ReNsed 1V17M