HomeMy WebLinkAboutCOM2010-00016 - COM CD Environmental Health Review - 2/18/2010 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Officialuse only/
415 N. 6th Street Permit Number: Ono-)rn (90 IO - Oi
PO Box 1666
Shelton, WA 98584 Date Received: .'i 1 v 1 . i t U
Shelton: (360) 427-9670, Ext. 400 Amount Received )
Belfair: (360) 275-4467 Ext. 400
Elma: (360)482-5269 Ext. 400 Receipt Number ,l-G I (
Fax (360) 427-8442
Applicant Information CL; AC:t-r Type of Review
Applicant 1\1 OCCk i-k wl Date ZA0 l0 0 Building Permit
Mailing Address P t C%j& 1cc.`,4 ❑ New ❑ Replacement
UWE_ 0S EOM Ok 9 i O 34 0 Commercial Building Permit
❑ New CIReplacement
City State Zip
S�3 .c-� CIBuilding/Commercial Permit Revision
c-s
Daytime Phone ,4 Zc Other Phone_f344 - Z4-1`6 I X Tenant Review
E-Mail Address C O NI l �`'-Cts ttAC_C C, _ csAk ❑ Pre-Application
Parcel Information
12-Digit Parcel Number I aA - 56 - CATLWD
Site Address �j,�Gi�'f I'll� c�� ��`� F 1 t- Li A 6i8 SzE,
i Street Number Street Name City
Type of Job Please submit a scaled plot plan
Describe work (:h �' ' t
"ei(Y-t-i showing all existing and proposed
,�' building, on-site sewage system,
Number of Bedrooms u and well.
On-Site Sewage Information Water System Information--
* On-Site Septic System CI New )4 Existing Plumbing in structure? lI 4es ❑ No
❑ Sewer Name of Sewer System (A-5-4 4 ' 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.
AppIi ant Sign ture
,� ` Date 2 — 'kC; `w
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System MC) 2-ird(fj
Tenant Review
Revision
Revised 12/17/09