HomeMy WebLinkAboutBLD Sewer Adequacy - 8/16/2022, . • ,60R10(22 - an8g
ENVIRONMENTAL RECEIVED
HEALTH AUG 1 6 2022
615 W. Alder Street
R N- 415 N.6TH STREET,BLDG 6,SHELTON WA 98564
MASON COUNTY SHELTON:360-427-9670,EXT.400
BEI.FA!R:360-275.4467,EXT.40G
t{�A. _`.) COMMUNITY SERVICES ELMA:360.482-5269,EXT.400
(440
� -::-�i\ ., Building Planning,Environmental Health,Community Health FAX:36C-427-7796
Application for Determination of Sewer Adequacy
Instructions:
1. Complete 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 properly.
>r Part 1:Applicant I Parcel Information
Applicant: V1'(I4,i. SiLiintr' -co✓ 3,9l?hq Si'Anbrd ail Date: 4,/1,19 0-t" )n.yi
Mailing Address '-l'4 54 A hec'. L,4-. 1.3- -- City, State,Zip:'1)0,.1- O,1 ct .f r W A 61. fr'--1
Site Address: 101 N 3 u elf ii 17' t+. Phone: ("1 i,, J •-1 1 v- t''-I 1'1
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Parcel Number: t 7-'?33 2_9 10 is c O 2 Permit Number. (3 17
Part 2: Sewer System Information
Name of Sewer System: SA el c. s,1'1r ; :1.4-:!„t/ Site Plan attached?
Official use only: Sewer System Manager or Designated Employee is to complete.
f New Connection: I have reviewed the applicants information and have no issues with Mason County Public Health approving the corresponding
Mason County Permit
jii Existing Connection: I have reviewed the applicants informatior and have no issues with Mason County Public Health approving the
corresponding Mason County Permit.
❑ I havo reviewed the applicants information and have determined sewer connection is currently NOT available to Ihis property
❑ Please add the following conditlon(s)on the corresponding Mason County Permit(optional)
�uSTln Pkt eq.,
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Printed Name of System Manager/Employe() it r tue of System Managed Employee J_— Date
Part : Mason County Public Health Review/Approval
Satisfactory ❑ Unsatisfactory ����1 ` (—ZAT1-
;lair��` Signature of Environmen Health Specialist
er✓1 a 1,1
+17 This form may be scanned and available for public view on the Mason County Web Site.
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