HomeMy WebLinkAboutBLD2012-00166 - BLD Letters / Memos - 4/13/2012 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES � JI
PO BOX 1666 Shelton WA 98584
April 10, 2012 Shelton (360)427-9670
Fax (360)427-8442
ROD FLAWS Elma (360)482-5269
16930 E STATE ROUTE 106 Belfair (360)2764467
BELFAIR WA 98528
Case No.: BLD2012-00166 Parcel No.:122205036010
Dear Applicant:
Your building permit will not be approved by Mason County Public Health until the following
items are completed and received in our office.
Application for water adequacy completed and signed by the water system manager.
Application for water adequacy completed and turned in.
Please call me at (360)427-9670, ext. 279 if you have any questions.
Sincerely,
Amanda Reynolds
Environmental Health
Mason County Health Services
Comments:
411012012 Page 1 of 1 BLD2012-00166
COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number: gu11
PO Box 1666 aa
Shelton, WA 98584 Date Received: V
Shelton: (360)427-9670, Ext. 400 Amount Received
Belfair (360)275-4467 Ext.400
Elma: (360)482-5269 Ext. 400 Receipt Number
Fax (360)427-8442
Applicant Information Type of Review
Applicant 1ti dD F14fd/S Date' IC Building Permit
Mailing Address /�/n.3y - 57,0 1D6 0 New 0 Replacement
�F �2 zx)yt. go-2e 0 Commercial Building Permit
City State zip 0 New 0 Replacement
36n a7f y-71e 3VO 5"3-1 /0I0 0 Building/Commercial Permit Revision
Daytime Phone Other Phone 0 Tenant Review
E-Mail Address 0 Pre-Application
Parcel Information
12-Digit Parcel Number
Site Address
Street Number Street Name city
Type of Job Please submit a scaled plot plan
Describe work uPLEx showing all existing and proposed
building, on-site sewage system,
Number of Bedrooms and well.
On-Site Sewage Information Water System Information
0 On-Site Septic System 0 New 0 Existing Plumbing in structure? i%Yes O No
19 Sewer Name of Sewer System 4LL.Y,y 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.
Applica Signature�-.� /
Date
Official use only
De artmentaI Review Approved Denied Notes
Water Adequacy
On-site Sewage System It t3 12-
Tenant Review
Revision
Revised 12/17/09
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