HomeMy WebLinkAboutCOM2012-00025 - COM CD Environmental Health Review - 4/10/2012 •
COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health
Official use onlyii
415 N. 6th Street Permit Number:-1 -10 I �—ti( :Z5--
PO Box 1666 �`(—
Shelton, WA 98584 Date Received: 3—
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
is
of Review
Applicant Information Type :
Applicant ��cn5cM Ci)v,n\ Date '3-?\ ❑ Building Permit
❑ New ❑ Replacement l
Mailing Address �1t `Y\o/ `- S one` ❑
W A Q`65�� Commercial Building Permit
0 New IX Replacement
City State Zip
El Building/Commercial Permit Revision
Daytime Phone `0�01 Other Phone 501- b3b1 ❑ Tenant Review
E-Mail Address -jker,•, c-z1•'�rv^crSNn-w,N.rIS ❑ Pre-Application
.
Parcel Information
12-Digit Parcel Number \3-33;--- S O- e 0°0-1
Site Address �, - l- `' 1 91- Cli. "A " EAC-46 r
Street Number Street Name City
Type of Job Please submit a scaled plot plan
S showing all existing and proposed
Describe work ��c th1 a1't el�4,t
0 ►� building, on-site sewage system,
Number of Bedrooms 0 and well. ,ruk4) Lo Rttfr,.(Se.kitf .
On-Site Sewage Information Water System Information
0 On-Site Septic System ❑ New 0 Existing Plumbing in structure? F(Yes ❑ No
Sewer Name of Sewer System \--k‘CA
:ir •
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.
Applicant Sign ture
Date 'j-;-1
1or 1�
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System 0-OlCi12-
Tenant Review
Revision
Revised 12/17/09