HomeMy WebLinkAboutBLD Sewer Adequacy - 9/22/2022 7.
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415 N.6TH STREET,BLDG 8,SHELTON WA 98584
// MASON COUNTY SHELTON:360.427.9870,EXT.400
. t ' \ COMMUNITY SERVICES BELfAIR:360-275.4487,EX7.4o0
ELMA:360.482.5289,EXT.400
j 7, Building.Planrdng,Environmental Health,Community Health FAX:380.427-7798
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 I Parcel Information
Applicant: Kn(4j,N(o /(l 7-1719 Date: 60_19 /90T)—��
' At City, State,Zip: trieR/J!-kF r 23 Web
Site Address: I I e 1::)./Yh0-11/ LLL-41 Phone:_'Riot.) Saq-ei 1
11 , dl5LO I
Parcel Number: 1�(�-� — t�7�qr permit Number_ ��13161
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Part 2: Sewer System Information `�I ll,�VL_ �-��- Lc�' "�
filf�bn� e ite Plan attached?
Name of Sewer System: Q�t NT4J
Official use only: Sewer System Manager or Designated Employee is to complete.
PNew Connection: I have reviewed the applicants information and have no issues with Mason County Pubic 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 this property.
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.
S-VAi• PLe Ip5 Sign PLLein
Printed Name of System I rragerl Employee ature of system Manager!Employee Date
Part 3: Mason County Public Health Review/Approval �V� \`I/f0(/0/*Satisfactory El Unsatisfactory JJJJJJ ����\\ Signature of Environm tat Health Specialist tjt Dale
444:4
This form may be scanned and available for public view on the Mason County Web Site.
RENSE0 3/2/2017