HomeMy WebLinkAboutCOM2011-00104 - COM CD Environmental Health Review - 5/21/2012 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official
use only
415 N.6th Street Permit Numbeco 1 l �_' - �.7✓�" I
PO Box 1666
Shelton, WA 98584 Date Received:
Shelton: (360) 427-9670, Ext.400 Amount Received
Belfair: (360) 275-4467 Ext. 400
Elma: (360) 482-5269 Ext.400 Receipt Number
Fax (360)427-7787
Applicant Information (� p Type of Review
Applicar D' l\` Date O Building Permit
Mailing Address_2 47
st'-n o New O Replacement
Commercial Building Permit WE)
Slate Zip "j1 New 0 Replacement
LI 7 0 Building/Commercial Permit Revision
Daytime h n er Phone 0 Tenant Review
E-Mail Address 0 Pre-Application
Parcel Information u
12-Digit Parcel Number �a � - I ,
Site Address Q ; '` �:' ) LE c e 3
Street Number Street Name City
Type of Job Please submit a scaled plot plan
Describe work showing all existing and proposed
building, on-site sewage system,
Number of Bedrooms and well.
On-Site Sewage Information Water System Information
r
0 On-Site Septic System 0 New 0 Existing Plumbing in structure? sf Yes 0 No
Sewer Name of Sewer System If yes: 1
Using an existing on-site septic system will req d'bnt 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 Signature
Date
Official use only
Departmental Review A roved Denied Notes
Water Adequacy tj , 1-2-
On-site Sewage System \C
Tenant Review
Revision
Revised 12/17109