HomeMy WebLinkAboutCOM2014-001110 - COM CD Environmental Health Review - 7/31/2014 ENVIRONMENTAL HEALTH REVIEW FOR CO UNITY DEVELOPMENT
Official use only
Mason County Public Health n ly. ppltp
415 N. 6th Street Permit Number: ,..j.
PO Box 1666 Date Received: a��0
Shelton,WA 98584
Shelton: (360)427-9670, Ext.400 Amount Received _ I_ —
Belfair: (360)275-4467 Ext.400 Receipt Number �7 7
Elma: (360)Fax 42-52
42769787. 400
Type of Review
Applicant information
�, FF1 Ga.,PRn CGC Date 7� �. Building Permit(commercial or residential)Applicant, 7W aye PnH '4a — )Oew O Replacement
Mailing Address l4roy ❑ Remodel O Revision
Ot c
State Zip Tenant Review
ab �2q•q Ilcation
Daytime Phone�o %ether Phone 36o a_ S° �8� 0 Pre-App
E-Mail Address Fer t"V C4yca.t'�—
Parcel Information 0
12-Digit Parcel Number 0 2' h i 98-584
city
Site Address W' eStreet Name
Street Number
Please submit a scaled plot plan
Type of Job Z- pyo )cRS showing all existing and proposed
I A n 1 t iW P(D✓e �� n building, onaite sewage system,
Describe work
Existing Bedrooms Proposed Bedrooms— and well. Max Size 11"x1T' .
Water System Information
On-Site Sewage Information Plumbing in structure? (Yes O No
On-Site Septic System ❑ New Existing
O 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.
gpplicanl�Si afure iJ _Date ZI 3
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE
Official use only
De artmental Review
p roved Date Notes, Conditions, Related Permit Vs
water Adequacy
On-site sewage System
Tenant Review
Revision Revised 111012014