HomeMy WebLinkAboutUntitled (525) RECEIVED
J U N 2 9 2022
5
615 W. Alder Street
v o
Public Health
Always working for a safer.m 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 all existing or proposed
sewer components and lines in relation to proposed development and property.
Part 1:Applicant I Parcel Information
Applicant: SCOTT, Jeff& Sabrina Date: 6-30-2022
Mailing Address: 815 29TH AVE E City, State,Zip: SEATTLE WA 981 1 2-41 37
Site Address: 568 E POINTES DR W Phone: (206) 713-3195 (206) 245-9259
Parcel Number: 12119-53-00080 Permit Number: I�JCi ?Q22 00817, 0681 S
Part 2: Sewer System Information
Name of Sewer System: HARTSTENE POINTE WATER-SEWER DISTRICT gr Site Plan attached?
Official use only: Sewer System Manager or Designated Employee is to complete.
® New Connection: I have reviewed the applicants information and have no issues with Mason County Public Health approving the corresponding
Mason County Permit.
O Existing Connection: I have reviewed the applicants information and have no issues with Mason County Public Health approving the
corresponding Mason County Permit.
❑ I 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)
Jeff Palmer, General Manager '—.r :-;� 6-30-2022
Printed Name of System Manager/Employee Signature of System Manager/Employee Date
Part 3: on County Public Health Review/Approval
Satisfactory ❑ Unsatisfactory 11 I t I yv7�
gnature 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