HomeMy WebLinkAboutCOM2010-00113 - COM CD Environmental Health Review - 1/5/2011 'OMMUNITV DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official useonly
415 N. 6th Street Permit Number: [ .nM 2L 10 00I f 3
PO Box 1666
Sharon,WA 98584 Date Received: I _5 4
Shelton:(3601427-961, Ext.400 400(360) 275 '.iAN c 2 amount Received # o�
Be rair. -4467 F-xt.
Elms:(360)482-5269 Ext. 400 Receipt Number �(. ao L I
Fax (360)427-7787
Applicant(Information Type of Review
Applicant i� h 'Sb n n Date F Building Permit
Mailing Address �1 .0- l43 ❑ New ❑ Replacement
I)hlnn A g859'a o merc' I uildi ermit
❑ ❑ placem
&00 8yg-4a�yg state Zip O Building/CommercialPermitRevision
Daytime Phone Other Phone Tenant Review
E-Mail Address O Pre-Application
Parcel Information
12-Digit parcel Number aa3a- s - G
Site AddressU�ill F b�l bi ill ic4r1 tS I t= D� or1t Uri '985912
Street Number _ Street Name -city
Type of Job ! Please submit a scaled plot plan
Describe work LAu)jot6u_ showing all existing and proposed
Number of Bedrooms .,A' building, on-site sewage system,
and well.
On-Site Sewage Information Water System Information
0( On-Site Septic System ❑ New 13 Existing Plumbing in structure? WYes O No
O Sewer Name of Sewer System If yes:
Using an existing on-site septic system will require a current submit ubmit a completed Water
maintenance report and a Record Drawing (Asbuilt). Documents Ad Form.
for both of these requirements may be on file with Mason y
County Public Health. Other requirements may apply.
. Applicant Signa#u e
Date / 3�
i
Official use only
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