HomeMy WebLinkAboutPAR2020-00060 - PAR Application - 3/25/2022 . ,soN co„,,,,
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Public .Ne, Healtti
. Always working for a safer a healthier Mason Coun iy
415 N,6th Street,Bldg 8, Shelton WA 98584 i
w60-427•,670 or 30O-275-4467,extension 400 i
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Application for Determination of Sewer Adequacy
Acct#400132
Instructions:
it` , 1,Complete Part 1 of application. Permit number may be added at later date.
„Z:Take application,.Site plan, and any ether gssoclated•infprrnation with the prbpoped flevelopment to the Sewer
System Manage 'or Designated Employee for approval,
3,,•Submit corn*ed application and Information to Permit Center orMason Count Public Health for review.
NOTE:You n us jsupply the System Manager.with a site plan for the project,i howing,all existing or proposed
sewer components and lines In relation to proposed development and propeirty. '
Part 1:Appilcdrit/Parcel Information •Applicant: -44* L''cA 1 L1f Arvk r/Date: i J ZS- Z
Mailing Address'.,.._ •d, ..0 0 it ZaS City, State,Zip: 1 CIA4i4 C t1 S h
Site Address: Ne4ctgQf to 23530 NE State Rt 3 ' Phone: WO - 710-AO
Parcel Number: 2 qi'443- 10210 Permit Number: Pfkr ZO'20- 0t106 b
Part 2: Sewer System Information
Name of Sewer System: ZA '( SCA&Xi (2fiTte Plan attached?
Official use only: Sewer System Manager or Designated Employee is to complete.
ga New Connection: I have reviewed the applicants information and have no Issues with Mason County Public Health approving the corresponding
Mason County Permit,
*fisting Connection' I have reviewed the applicants information and have n•Issues with Mason County Pudic Health approving theorraeponding Mason County Permit.
❑ I have reviewed the applicants information and have determined sewer connection is currently NOT available to this property.
if Please add(rthe fallowing conoIHion(s)on the
ee-corresponding Mason�Counnty Permit:(optional ii
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Printed Name of System Manager/Employee tgnsture of System Manages Employee Date _
Part 3: Mason County Public Health Review/Approval J�n^ ('� �����Z�
Satisfactory 0 Unsatisfactory �� 1 it`c1JV 7
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Signature of Environtftentai Health Specialist ate
This form may be scanned and available for public view on the Mason County Web Site.
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03/25/2022 03:26PM 3602773191 LOCAL WRENCH PAGE 02
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