HomeMy WebLinkAboutBLD Sewer Adequacy - 9/22/2022 Lc f- I
~ 415 N.6Tli STREET,BLDG 8,SHELTON WA 98584
aiireei) MASON COUNTY SHELTON:380.427-9870,EXT.400
%An . ) COMMUNITY SERVICES BELFAIR:360-275-4467,EXT.400
ELMA:360.482-5269,EXT.400
Building,Planning.EnvironmentalHealth,CommunityHealth FAX:360-427-7798
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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
Applicant:Kf(A,f/N(9 /('l T5f e Date: aa/2v21-
Mailing Address:PNc(N 13GtGKt-1 nt1411-1../a City,State,Zip:&LviER.IJfatf_ VIA13.12323
Site Address: 2C-% G C�i.)LIYCtJ1.LL, t '4 r1 Phone: L O 6"�-4/(1-P4/
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Parcel Number. /a2a/ - - ca ikj1 Permit Number' B )f 1 26. z Lf(,
Part 2: Sewer System Information /n - �� Lilt
Name of Sewer System: lI OA./ 00t�N r 7,/ Site Plan attached?
Official use only: Sewer System Manager or Designated Employee Is to complete.
53, 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.
❑ I have reviewed the applicants information and have determined sewer connection Is currently NOT available to Ihts property.
Please add the following condition(s)on the corresponding Mason County Permit(optional)
Follow Mason County Sewer Design and Construction Standards.Schedule
Inspecitons with System Manager.Pay Connection Fee Charges of$11,954.72.
P4. icy/2L
Printed Name of System Managed Employee ignaturo d System Manager/Empbyoo Date
--
Part 3: Mason County Public Health Review/Approval 1.
6-072
Satisfactory ❑ Unsatisfactory
Signature of Environment
�H�eaahhh Specialist Date
En of
This form may be scanned and available for public view on the Mason County Web Site.
RENSEo 3.12/2011