HomeMy WebLinkAboutBLD2013-00099 - BLD CD Environmental Health Review - 2/14/2013 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number XiA9 -0
PO Box 1686
Shelton, WA 98584 Date Received: — - 1 3
Shelton: (360)427-9670, Ext 400 r-
Belfair: (360)275-4467 Ext. 400 Amount Received
Elma: (360)482-5269 Ext.400 Receipt Number
Fax (360)427-7787
Applicant Information Type of Review C /
Applicant r r n C ` j k Date_ZL/1-13 0 Building Permit f1 kzp": O^ e,
Mailing Address 5-0 .A/,E t>_ 4 •'�..�� C-E O New 0 Replacement
al ILr (A)A gg5a O Commercial Building Permit
City State Zip 0 New 0 Replacement
3&0-& zY 0 Building/Commercial Permit Revision
Daytime Phone vows Other Phone z3ra•/-i6B£'
0 Tenant Review
E-Mail Address 0 Pre-Application
Parcel Information
12-Digit Parcel Number I 3u i-0'000 Y
Site Address 5Z) p S,o c C-(-
Street Number Street Name city
Type of Job Please submit a scaled plot plan
p'4 'ro { R e eft if showing all existing and proposed
Describe work SvD
building, onsite sewage system,
Number of Bedrooms 3 and well.
On-Site Sewage Information Water System Information
0-On-Site Septic System 0 New A(Existing Plumbing in structure? IXYes 0 No
0 Sewer Name of Sewer System 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»�nt Signature -7 /y
!� Date
Official use only
Departmental Review Approve Denied Notes
Water Adequacy
On-site Sewage System Z
Tenant Review
Revision
Rwised 12117MO