HomeMy WebLinkAboutBLD Sewer Adequacy - 9/22/2022 Lo -
y,•,:p� 415 N.6TH STREET,BLDG e,SHELTON WA 98564
e' 1 MASON COUNTY
�7 7 SHELTON:360-427-9070,EXT.400
1. 4I I COMMUNITY SERVICES BELFAIR:380-2754467,EXT.400
\ _ ELMA:360-482-5269,EXT.400
\ Buildln9.Planning.Environmentaltleatih,CommunllyHeahb FAX:360-427-7798
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: N(luj l W. Ifs 1 7-1 RPDate: i I ;�/9U`}'�
Mailing Address:pig is fiycLK�►tv1/iLc 2fl City,State,Zip: ��t.triFa¢(3/4[F_(((knli9, `03$3
Site Address: 1-I v _. �ti�YIALI (4LA Phone:r Q— 15�G{—�-LYQ I
^ U T— _
Parcel Number: )d a.2O " (il) — 62 l It.01 Permit Number: 3I 1 26 L:2 -0 15La5
Part 2: Sewer System Information �Q yam_ , t A
Name of Sewer System:_MitSp/. a/A/VW Site Plan attached?
Official use only: Sewer System Manager or Designated Employee Is to complete.
rip New Connection: I have reviewed the applicants information and have 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.
n I hove reviewed the applicants information and have determined sewer connection is currently NOT available b this property.
Y" Please add the following condilion(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.
-31)Sh^i` Pl ti ../A . .i/...' IDNIit _
Printed Nine oI System Manager, /Emplxyoo .Ignatvre of System Manager!Employee Data
Part 3. Mason County Public Health Review/Approval CON l c (' 7
'1'_y(Satisfactory ❑ Unsatisfactory I l
w Signature of Environment eallh Specialist n �Date
(�V wit 1 C/A-- J�CS3c1'Y
This form may be scanned and available for public view on the Mason County Web Site.
IREVSED 317.12017