HomeMy WebLinkAboutBLD CD Environmental Health Review - 3/21/2011 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number:
PO Box 1666 rr V,',
Shelton,WA 98584 Date Received: - ZI- ZO If
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 Jkx',ka I jnllnbon Date 312 �/ O Building Per�mitReplacement
Mailing Address a33� r'ahI iL�/G
2r�r 40 1992 Commercial Building Permit
City
State - Zip 0 New 0 Replacement
_a,y O Building/Commercial Permit Revision
Daytime Phone 941G Other Phone Tenant Review
E-Mail Address 0 Pre-Application
FDescribe
ormation
arcel Number I aviM -L4 O I d I ��
ess l o nE '�� JubL- 12I
Street Number Street Name Uny 6185 2
ob Please submit a scaled plot plan
showing all existing and proposed
work building, on-site sewage system,
Number of Bedrooms and well.
On-Site Sewage Information Water System Information
0 On-Site Septic System 0 New 0 Existing Plumbing in structure? 0 Yes 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.
EAp ni Signature
r Date 3 /.l4zz_Li
Official use only
W
eview A roved Denied Notesstem
Revlsetl 12/17/09