HomeMy WebLinkAboutCOM2011-00031 - COM CD Environmental Health Review - 6/6/2011 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number: ` '/m�ni I -ow_
PO Box 1666
Shelton,WA 98584 Date Received: -In- I I
Shelton: (360)427-9670, Ext. 400 Amount Received l
Belfair: (360) 2754467 Ext. 400
Elma: (360)482-5269 ER.400 Receipt Number
Fax (360) 427-7787
Applicant Information, I Type of Review
Applicant mt 1L v�YAe'UI Date,4-i52oii ❑ Building Permit
❑ New ❑ Replacement
Mail' Addy I IC nc n0etlt--�htnz ❑ Commercial Building Permit
1} ati (�Jrt1 �IS5Z8
❑ New ❑ Replacement
Off, State ZIP
t 0 CIS-43o5 ❑ Building/Commercial Permit Revision
Dayf�me Phone Other Phone Tenant Review
E-Mail Address ❑ Pre-Application
Parcel Information 12-Digit Parcel Number _ 1�k 3A " 50 (C I O �j
Site Address
Street Number Street Name Off'
Type of Job Please submit a scaled plot plan
[Wr showing all existing and proposed
Describe work building, on-site sewage system,
Number of Bedrooms and well.
On-Site Sewage Information water System Information
❑ On-Site Septic System ❑ New ❑ Existing Plumbing in structure? yYes ❑ No
❑ Sewer Name of Sewer System w I I I 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.
Ap cant Sig u
n, Date
4 Official use only
De artmental Review A roved Denied Notes
Water Adequacy
On-site Sewage System 2`I _ o..la Ii nEtt) IDLli 'A'L� -
Tenant Review —
Revision
Revised 12M�/09