HomeMy WebLinkAboutBLD2011-00709 - BLD CD Environmental Health Review - 8/26/2011 (2) >
COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only C7 415 N.6th Street Permit Number: 31d 241 I 06`7O 1
PO Box 1666 2
Shelton,WA 98584 Date Received: �t10-60�n
Shelton: (360)427-9670, Ext. 400 Amount Received 8-Z�0'[-U Belfair: (360) 275-4467 Ext.400
Elms: (360)482-5269 Ext. 400 Receipt Number
Fax (360)427-7787
Applicant Information Type of Review
Applicant y TOHAI FR IE N D�1'>i Date l/ ■ Building Permit
Mailing Address P10� l�X 2055 V New 0 Replacement
eac 1 ft� . WA, 795-0- 0 0 Commercial Building Permit
City l State Zip 0 New 0 Replacement
3E0`�7a''fr(Q 0 Building/Commercial Permit Revision
Daytime Phone 'Other Phone
_ AIR �Gaee pview
E-MailAddress FRANCa5,FREUp peation Parcel Information
12-Digit Parcel Number 12330 - '15- 40042
Site Address N iE /SI aiu rAllfY MA A bR aft Q El Fiq l�
Street Number Street Name City
Type of Job Please submit a scaled plot plan
Describe work EXPAIVd showing all existing and proposed
Number of Bedrooms building, on-site sewage system,
and well.
On-Site Sewage Information Water System Information
f On-Site Septic System 0 New ■ Existing Plumbing in structure? ■Yes O No
0 Sewer Name of Sewer System If yes:
Using an existing on-site septic system will require a current submit a completed Water
s Please maintenance report and a Record Drawing (Asbuilt). Documents ple PleAdequacyForm.
for both of these requirements may be on file with Mason
County Public Health. Other requirements may apply.
Applicant Signature- i�� o a�
y � Date O�
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System t
Tenant Review
Revision
Revised 12/17/09