HomeMy WebLinkAboutBLD2010-00066 - BLD CD Environmental Health Review - 2/2/2010 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number: -' 020in -
PO Box 1666
Shelton, WA 98584 Date Received: I O
Shelton: (360)427-9670, Ext. 400 Amount Received
Belfair: (360)275-4467 Ext. 400
Elma: (360)482-5269 Ext, 400 Receipt Number Cln�6( Z1
Fax (360)427-8442
Applicant Information Type of Review
Applicant Ro I-D V Date -a-/ Building Permit
Mailing Address p6' k,x No y3 _j( New 13 Replacement
�mV J�Ov\ Lift y g� ,j. O Commercial Building Permit
city State Zip 0 New D Replacement
Daytime Phoneo-Z[o s3�th r Phone O Build ing/Commercial Permit Revision
O Tenant Review
E-Mail Address (66y',AeL� cDM_e,fv [OVw% p Pre-Application
Parcel Information
12-Digit Parcel Number 133 b5 - Sb - boo 3S
Site Address I�iO nsr .J -.r �m<, - ¢.l ro. : /
Street Numbed Stre t Name city
Type of Job Please submit a scaled plot plan
Describe work IV[o rvs�JU c�.o ^ showing all existing and proposed
building, on-site sewage system,
Number of Bedrooms 3 and well.
On-Site Sewage Information Water System Information
O On-Site Septic System jq New 0 Existing Plumbing in structure? O 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.
Applic nt Signature
L Date
Official use only
Departmental Review Appr9yed Denied Notes
Water Adequacy CE
On-site Sewage System Zy
Tenant Review
Revision HEN( 4TAL
Revised 12/17/09