HomeMy WebLinkAboutBLD2011-00238 - BLD CD Environmental Health Review - 4/1/2011 (2) COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number: bIcIZ.0 i II ~ OCLW)
PO Box 1666• Shelton,WA 98584 Date Received: '44 - dO I
Shelton:(360)427-9670, Ext. 400 Amount Received i��7.CP
Belfair: (360) 275-4467 Ext.400 l `
Elma: (360)482-5269 Ext. 400 Receipt Number _
Fax (360)427-7787
Applicant Information / Type of Review
Applicant
`�G C U A/ Date 1[ &?J/( "Building Permit
Mailing Address 7° 1 / 7 /`-)r ?7/3v • o' New 0 Replacement
G U-ns 4 4 6 01 f ❑ Commercial Building Permit
❑ New 0 Replacement
City State Zip
0 Building/Commercial Permit Revision
Daytime Phone Other Phone l f,e,"7-7/:r31, p Tenant Review
E-Mail Address_ ❑ Pre-Application
Parcel Information
12-Digit Parcel Number- 072 3 /t 76 .. 6o /(oo
Site Address i`' r ^•6-7- c?` .01a "A y Fe i Cia;—
Street Number Street Name City
Please submit a scaled plot plan
Type of Job
a- showing all existing an proposed
Describe work +L building, on-site sewa system,
Number of Bedrooms 3 and well.
On-Site Sewage Information
Water System information
C3'On-Site Septic System ❑ New xisting Plumbing in structure? Efies 0 No
0 Sewer Name of Sewer System 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. 1
Applica t ign y(/t / //
f� Date I
Official use only
Departmental Review Approved Denied Notes
Water Adequacy W)4 20li 0.CACe �•
On-site Sewage System �� I2ro1 t
I
Tenant Review I
Revision
Revis4d 12/17/09
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