HomeMy WebLinkAboutPeople Living on Parcel with No Record of Living Quarters - BLD Letters / Memos - 7/19/2010 Case Number: f'C"i 0
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Mason County Investigation Report Form
Parcel Number: 3 & - - 00q
Violation Site Address: 7/
Property Owner(s): 10MInt4Tll t%1 t/Yl ) Phone#:
Mailing Address: 71 C ///D
Tenant/Contractor/Operator on site:
Directions to Site:
Description of Concert: �'—
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Under the provisions of the Public Disclosure Law, RCW 42.56.240, the complainant may indicate a
desire for disclosure or non-disclosure of their identity. If non-disclosure is chosen, the bottom portion of
this form will not be released to the public unless this case is filed in court. If filed,your name will be
disclosed if you are a witness in the case.
Mason County investigates possible violations on a complaint basis only. Therefore,the name of the
person filing the complaint should be provided.
Please Check One Of The Following Lines:
❑ Please do not disclose my identity. I understand that disclosure may be required by court
order or if this matter goes to court.
❑ You may disclose my identity.
Name(please print): � Phone: ( )
Address: Jr�kl Ulm
Street Cityto Zip
Signature of Complainant: v Date:
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oncern: Building_
Environmental_Health: Solid On-site Wells. Food Other
Wyest gation Date,and Findings:
Date Closed: Reason Closed: Initials:
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