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HomeMy WebLinkAboutBLD Sewer Adequacy - 9/22/2022 )r�'''ti�\ 415 N.0TH STREET,BLDG 8,SHELTON WA 98584 t :\1 MASON COUNTY SHELTON:360-427-9870,EXT.400 s BELfAIR:360-275.4467,EXT.400 `.- 1 COMMUNITY SERVICES ELMR:360-275.4467,EXT.400 ff Bwldtn9,Planning.Environmental Health,Community Health FAX:360427-7)98 ���IT 4 Application for Determination of Sewer Adequacy Lb 19 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 I Parcel Information n�1 Applicant:ilflC4JtN(0 I(1 T5fl(Date: I pr1/9()91— Mailing Address:?„41LjL Nft1 i3ttedetrl/YN/u_Rr City,State,Zip:&Lire-J3laCf��Weli 1 E3 `�1 Site Address:L l r1 i Lb41e Phone:_,-/f2 SQ `" 1 I— q Parcel Number: 1 " — [iQD Permit Number: 1 k 1 1 L c/' - ( r 5 L�_3 Part 2:Sewer System Information i�]'�-- LC'` - Name of Sewer System: )11115 jjA/J �i(&AITV fie<elan attached? r Official use only: Sewer System Manager or Designated Employee is to complete. 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 hove reviewed the applicants information and have determined sewer connection Is currently NOT avaiable to this property. al Please add the following conditions)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. Svs Nt.I il0.44.• )o%/2Z Printed Name of System Manager/Employee Signature of System Manager/Employee Data Part 3: Mason County Public Health Review/Approval)] Satisfactory ❑ Unsatisfactory l/v/ZJ Z /\ Signature of Environment eaith Specialist - (Yte COT\C�l its`•/v1 L. JI 4 This form may be scanned and available for public view on the Mason County Web Site. REVISED YL2017