HomeMy WebLinkAboutBLD2014-00318 - BLD CD Environmental Health Review - 3/21/2014 ENVIRONMENTAL HEALTH REVIEW FOR COMMUNITY DEVELOPMENT
Mason County Public Health Official use only MM��415 N. 6th Street Permit Number: 7ni 14-O 13,19
PO Box 1666 SAC 1
Shelton, WA 98584 Date Received:
Shelton: (360)427-9670, Ext.400 Amount Received
Belfair: (360)2754467 Ext.400
Elms: (360)482-5269 Ext. 400 Receipt Number
Fax (360)427-7787
Applicant Information Type of Review
Applicant Jivt Rc.�as�a.�2 Date3al / O Building Permit (commercial or residential)
Mailing Address 743/ /J 13 New Cl Replacement
.Sdta On. h U//R- gQ SBy O Remodel O Revision
City 36y gmo State Zip
3� 0 Tenant Review
Daytime Phone s9/u Other Phone 9- !n0 0 Pre-Application ,1
E-Mail Address W // kQ ;(,c o�(
Parcel Information re4%dr
12-Digit Parcel Number 112 O/ — lq—op
Site Address Zyj/ Z�) SAE Corr J/2e 1p'7 Ill/?
Street Number Street Name City %f,S'bi/
Type of Job Please submit a scaled plot plan
Describe work /Uo Me- S�rac><u showing all existing and proposed
building, on-site sewage system,
Existing Bedrooms D Proposed Bedrooms and well. Max Size 11"x17".
On-bite Sewage Information / Water System Informati�on�
Or
Septic System 0 New x/isting Plumbing in structure? 6r Yes 0 No
O Sewer Name of Sewer System If yes:
Using an existing on-site septic system will require a current ease submit a completed Water
maintenance report and a Record Drawing (Asbuilt). Documents Please
AdequacyForm.
for both of these requirements may be on Tile with Mason
County Public Health. Other requirements may apply.
Applicant Signature
(' Date
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE
Official use only
Departmental Review Approved Date Notes, Conditions, Related Permit#is
Water Adequacy
On-site Sewage System
Tenant Review
Revision
Revised 1110/2014