HomeMy WebLinkAboutBLD Sewer Adequacy - 9/22/2022 a fir, 415 N.6TH STREET,BL 8,SH ON WA98584
*\ BE
MASON COUNTY SHELTON:380-427-9870,EXT.400
• LFAIR:380.275.4487,EXT.400
Pi . � l COMMUNITY SERVICES ELMA:380482-5289,EXT.400
g404ar' Buikling,Planning.Envlronmental Health,CommunilvHeallh FAX:380-427.7798
l y
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 I /
Applicant: 11111.4,41 s I(I T1 AV Date:
Mailing Address: it•I Nl+J/3/. 4.ta-f iv ri-1l t-GRF1 City,State,Zip: ccLvF-Q J3/ WA,
13
Site Address: 11 ET (.l�It:1�1QJ1 1 t�1✓1 LCi 11t hone: — c—epic?!
Parcel Number:j d 2Lf—`St ls7 S Permit Number: LC)ZZ - () l 5'3`C;
Part 2: Sewer System Information /� :4i �� (� SS Z�-{-
Name of Sewer System: / AvA/ &V./1 ' TSite Plan attached'?
Official use only: Sewer System Manager or Designated Employee is to complete.
67 New Connection: I have reviewed the applicants Information and have no Issues with 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
corresponding Mason County Permit.
0 I have reviewed the applicants Information end have determined sewer connection Is currently NOT available to this property.
tg Please add the following condition(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.
�u5�tn Pket?'S Sig
Printed Name GI System Managd ye r Emploe nature of System Manager!Employee Dale
Part 3: Mason County Public Health Review/Approval � /
Satisfactory CITI,�Unsatisfactory N a�c y n' ` 1 /6 ( Zc
Signature of Environm ntal Health Specialist ale
J r�tn-S
This form may be scanned and available for public view on the Mason County Web Site,
REVISED 3/1R017