HomeMy WebLinkAboutCOM2014-00003 - COM CD Environmental Health Review - 1/9/2014 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number: C prr)W H -001203
PO Box 1666
Shelton,WA 98584 Date Received: I Z�
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 Type of Review
Applicant I W Date • 6•1�I P( Bing Permit
Mailing Address //J4S�.E47 //�/1• �.YJI1Yr �� ,Zing
0 Replacement
,::�o j!k Commercial Building Permit
City State Zip X New D Replacement
DaytimeorSS� Other Phone 0 Building/Commercial Permit Revision
O Tenant Review
E-Mail Address CydrkS' @L6r•'x�'Sr1 O Pre-Application
Parcel Information
12-Digit Parcel Number f�IZ `i'G.2"(Y7l�b
Site Address 5/ ]JE }ZF R�/_ --rV A5b5" i? ((,I
Sncet Number Street Name Cay
Type of Job Please submit a scaled plot plan
Describe work 1VF1J 'L 5Z!?S/ 15a*75F showing all existing and proposed
building, on-site sewage system,
Number of Bedrooms and well.
On-Site Sewage Information Water System Information
M On-Site Septic System 0 New 0 Existing Plumbing in structure? XYes O No
YSewer Name of Sewer System aaf}}AZ 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.
A Sig
Date� S
Official use only
De artmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System 00 lrj
Tenant Review
Revision