HomeMy WebLinkAboutCRT2021-00060 - CRT Application - 4/21/2001 MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SHELTON, WA 98584
(360)427-900
FAX 427-7798
APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW
Receipt No: '��i' ��, �ZZ I
I Date of Payment: I
Septi pL Water Review ($85) : I add
Both ($100) : I aan)3�aa
Property Evaluation ($85+$50/Hr) :
INSTRUCTIONS � -r
[�L' 2co I he
1. M application is considered complete when the fee to paid, Parts t•A of the application foie are eonpleted.
(assistance Milt be provided upon request for cmplecim Part Two), the necessary paperwork 1s attached, and
required soft evaluation holes have been excavated.
2. After a cmpleted application is received, staff Mill inspect the property and provide the applicant with a
written report.
3. If the site review requires more than i hour of work, the department will c arse the appti t en additional
hourly rate of f50/hour as set forth by the Mason County Board of Health. x orb r--{N] "
PART 1: APPLICANT/PARCEL IDENTIFICATIOWP)'
n ` A3. ,b-(nSd -777SI
NAME OP APPLICANT 'lf6'G��S t//'77GG E� TELEPHONE (Zee ) 61V- 70$`3
SITE/HOUSE ADDRESS /(//i IlF 64'LLCY mftl / /^
ins- vary
MNILING ADDRESS
/N IL/ L`FS'ZY ACREAGE 3
Ci[y State 2 p
ASSESSOR'S PARCEL NUMBER i �_� - r�S - C--) C3 G ) _I_
LEGAL PROPERTY DESCRIPTION "F
SUBDIVISION (If Applicable) DIV s BLK LOT
DI7TONS FOR LOCATING SITE 4W 5A JM
Sketch location of property in this apace.
I /yr ,bc (Avw ro
I CurafT �
j °dy I
X:IIX!-SIT6l9AaVIbM.w Revision 2126199 Page 3