HomeMy WebLinkAboutBLD Sewer Adequacy - 9/22/2022 rll--- -.\ri
ot. +e 415 N.8TH STREET,BLDG 8,SHELTON WA 98584
\ MASON COUNTY SHELTON:360-427.9870.EXT.400
..t COMMUNITY SERVICES BEELMA:360-075-4467,EXT.400
\,(,—�' j Building,Planning,Environmental Health,Community Health FAX 760.427.779E
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!Parcel Information rl
Applicant: KllG,S1/,i(n ,K171IIP Date: Cii 2/9v?1—
Mailing Address:ip-i4 N4)A/Acda.1 NI-ha-Rr City,State,Zip: Vic/WM.4 VIA 5.2313
Site Address: 44 12)E. Wi411.42: 1G-6'l LAC hone: 3/41/2-67.:q— 4/41q1
Parcel Number. /,7,230- to,- &6006, ermit Number: i6I 2,62 d i ( 'U
Part 2: Sewer System Information ":A l t t,i.'y_.,i...! A
Name of Sewer System: McK0A/(2,fatAiTY 1E552L'Site Plan attached?
Official use only: Sewer System Manager or Designated Employee is to complete.
New Connection: I have reviewed the applicants information and nave no Issues with Mason County Public Health approving the corresponding
Mason County Permit.
0 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.
Vi Please add the following condiUon(s)on the corresponding Mason County Permit:(optional)
Follow Mason County Sewer Design and Construction Standards. Schedule
inspections with System Manager. Pay Connection Fee Charges of$11,954.72.
3---VS'6 PLe.tp5 ,14414‘ aviu- lath"._. _
Peeled Name of System Manager/Employee tgnature or System Manager/Employee Data
Part 3: Mason County Public Health Review!Approval (� /
N,c /Satisfactory El Unsatisfactory Unsatisfactory Q JA l��1 L�
\ Signature of Environmental Heal h Specialist/ n D
u'�UL/A-\1 1 X- l •(2
This form may be scanned and available for public view on the Mason County Web Site.
REVISE°7R/2017