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Home My WebLink AboutBLD Sewer Adequacy - 11/7/2023 ,. Public r..� Health Always working for a safer i healthier Mason County 415 N.6th Street,Bldg 8.Shelton WA 98584 360-427-9670 or 360-275-4467.extension 400 Application for Determination of Sewer Adequacy Instructions: 1. Complete Part 1 of application. Permit number may be added at later date. 2.Take application, Site plan, and any other associated information with the proposed development to the Sewer System Manager or Designated Employee for approval. 3. Submit completed application and information to Permit Center or Mason County Public Health for review. NOTE:You must supply the System Manager with a site plan for the project,showing ail existing or proposed sewer components and lines in relation to proposed development and property. Part 1: Applicant/ Parcel Information Applicant: -11111fN pit 111J►n N LL-1'_ Date: 1�l /V3 (gyp Mailing Address: 2\rjr� �o Lf�X� W A`� City, State.Zip: 6 -TT kJ c i o3 - -- SiteAddress PoUTE to(p Phone: toter-' 3(70 1 Co"aq'-43 U010N Wit- '1 cCSit Parcel Number: 3 a A 3 3 -Sb -0 001l0 Permit Number: - -fat? Part 2: Sewer System Information (ck'a Name of Sewer System: 4 c ccv4 .ii r & C,Site Plan attathed"r Official use only: Sewer System Manager or Designated Employee is to complete. 0 New Connection: I have reviewed the applicants intormation and have no issues witn Mason County Public Health approving the corresponding Mason County Permit. Existing Connection: I have reviewed the applicants information and have no issues with Mason County Public Health approving the 111 corresponding Mason County Permit. j] 'have reviewed the applicants information and have determined sewer connection is currently NOT available to this property. ❑ Please add the following condition(s)on the corresponding Mason County Permit'(optional) 3c-14l3 6't'65o10 - 1111123 Printed Name of System Manger/Employee Signature of System Manager/Employee Date Part 3: Mason County Public Health Review/Approval ❑ Satisfactory ❑ Unsatisfactory Signature of Environmental Health Specialist Date This form may be scanned and available for public view on the Mason County Web Site. REVISED 10,28/2015