HomeMy WebLinkAboutPAR2014-00057 - PAR Application - 8/6/2014 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Official use only
Mason County Public Health
415 N. 6th Street Permit Number:
PO Box 1666
Shelton, WA 98584 Date Received:
Shelton:(360)427-9670, Exl.400 Amount Received
Belfair: (360)275-4467 Ext.400
Elma: (360)482-5269 EM.400 Receipt Number
Fax (360)427-7787
Type of Review
Applicant Information
Applicant Date o Building Permit
p� New O Replacement
Mailing Address 1521 2"a A✓k A 2(00 Qb'/0 f p comylercial Building Permit
SC�X o (� E New O Replacement
city Slate ZIP
O Building/Commercial Permit Revision
Daytime Phon So9 4UbOther Phone O Tenant Review
E-Mail Address S'7Grn�i l CrJM O Pre-Application
Parcel Information
12-Digit Parcel Number
�2462 24 9Ch1�)
Site Addresses)&) e5 Cuy
Shcef Number Shm Name
Type of Job Please submit a scaled plot plan
showing all existing and proposed
Describe work ' 502 'J�u. Icl ou_+ TT building, on-site sewage system,
Number of Bedrooms R" and well.
On-Site Sewage Information
Water System Information
O-On-Site Septic System O New I Existing Plumbing in structure? eYes O No
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.
Applicant Sig Date 08/06/2014
Official use only
De artmental Review A roved Denied Notes
Water Adequacy
On-site Sewage System
Tenant Review
Revision