HomeMy WebLinkAboutBLD2022-01088 - BLD Sewer Adequacy - 5/25/2022 • . ,fa�c a,0 a 2 - 6/08 8
ENVIRONMENTAL RECEIVED
HEALTH AUG 1 6 2022
615W. Alder Street
,7' n4rQ 415 N.6TH STREET,BLDG 8,SHELTON wA 98564
(C t. MASON COUNTY SHELTON:360-427-9670,EXT.400
'„ tiff _:`' COMMUNITY SERVICES BEI FAIR:360-275-4467,EXT 400
--;y,--� �r:.},4 ELMA:360-462-5269,EXT.400
ii '-67' Building,Ptann•ing,Environmental Noah h,Community Health FAX:36C-427-7798
Application for Determination of Sewer Adequacy
Instructions:
1.Cemplete Part 1 of application. Permit number may be added a!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.
B Part 1:Applicant/Parcel Information
Applicant: i/t'Kk.i. S ,i�nt.t' -1,o4, ' l h(1 S)n,-.br_lan Date: e—A 0-.ty 1-0'2-2-
•Mailing Address '1-l5cf Ah,4-, c4-. t.). City. State,Zip:'pa4-, ace.hc..jtf , b4A i33(n'1
Site Address l 01 ) 1, ev ri f)'', Phone: ()i 4,v ) •-t I U- (a 4 f','-t
Parcel Number: 1 Z 3'.3 2.j I C>oc)O 2- Permit Number (3 (7
Part 2: Sewer System Information
Name of Sewer System: `e.,j- A,,',i ;, .,.a.),•, " q Site Plan attached?
Official use only: Sewer System Manager or Designated Employee Is to complete.
n New Connection: I have reviewed the applicants information and have no issues with Mason County Public Health approving the corresponding
Mason County Permit
Ti 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.
D Please add the following condition(s)on the corresponding Mason County Permit:(oplional)
-3—ustln Phe rs /4.44 ,1fq. f 2122Printed Name of System Manager/Employee ure or System Managed Employee Dale
Part : Mason County Public Health Review/Approval
pi Satisfactory ❑ Unsatisfactory "11' l z(27 —
Signature of Environmen I Health Specialist
-i-t This form may be scanned and available for public view on the Mason County Web Site.
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