HomeMy WebLinkAboutCOM2012-00011 - COM CD Environmental Health Review - 2/8/2012 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. street Permit Number. 1
PO Boxox 1666
re
Shelton,WA 98584 Date Received:
Shelton:(360)427-9670, Ext.400 Amount Received 5
Belfair: (360) 275-4467 Ext. 400
Elma: (360)482-5269 Ext. 400 Receipt Number Z!(a CC)
Fax (360)427-7787
Applicant Information Type of Review
Applicant NLttL l IGY_L Date L 6-lsl1 0 Building Permit
Mailing Address (�S p l o New 0 Replacement
�l l6, / t,)A 485-SN 0 Commercial Building Permit
city State Zip 0 New 0 Replacement
Daytime Phone o-1353 Other Phone 416- 05-7 y O Building/Commercial Permit Revision
eTenant Review
E-Mail Address dnw016na5tok0h_141 - com O Pre-Application
Parcel Information
12-Digit Parcel Number 3 213b-Z `I - 311
Site Address 5981 tc 54afe R1' 3W�4�S8y
Street Number Street Name city
Type of Job Please submit a scaled plot plan
Describe work Cju&n It- Tti, t showing all existing and proposed
, � Ip building, on-site sewage system,
Number of Bedrooms and well.
On-Site Sewage Information Water System Information
O On-Site Septic System 0 New O Existing Plumbing in structure? ❑ Yes No
O Sewer Name of Sewer System rorix '?-ItA /\
r 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.
Applicant Signature
Date Z-(,- ZD I ?
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-she Sewage System Z
Tenant Review
Revision
Revised 12/17/09