HomeMy WebLinkAboutBLD CD Environmental Health Review COMMUNITY SERVICES ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N.Sin Street Permit Number:
Shelton,WA 98584
Shelton:(360)427-9670,Ext.400 Date Received:
Beffair: (360)275-4467 Ext.400
Elma: (360)482-5269 Ext.400 Amount Received:
Fax (360)427-7787 Receipt Number:
Applicant Inform tl n Type of Review
Applicant C-�k77 F S Date '? 3 I(o 0 Building Permit
Mailing Address v7re, Ave. `.kc 0 New 0 Replacement
L,)� g1533:1 ❑ Commercial Building Permit
City state Zip 0 New M Replacement
01(- 0 Building/Commercial Permit Revision
Daytime Phone3c04-/8 Other Phone
O Tenant Review
E-Mail Address ✓ Pre-Application
Parcel Information
12-Digit Parcel Number ta30).9 4a oel90
Site Address 31 k E a r (� '-✓H `i S,-i%�
Sweet Number SmetNmee Cby
Type of Job Please submit a scaled plot plan
Describe work - rc showing all existing and proposed
building, on-site sewage system,
Number of Bedrooms and well.
On-Site Sewage Information Water System Information
0 On-Site Septic System O New 0 Existing Plumbing in structure? P^'Yes 0 No
Sewer Name of Sewer System�11c If yes:
Using an existing on-site septic system will require a current 7 Please submit a completed Water
1 maintenance report and a Record Drawing (AsbuilQ. Documents Adequacy Form.
1111 for both of these requirements may be on file with Mason
County Public Health. Other requirements may apply.
:Applicant Sign ure 11-.�
Gate 6 ' Q— 1
Official use only
Departmental Review Approved I Denied Notes
Water Adequacy
On-site Sewage system
Tenant Review
Revision