HomeMy WebLinkAboutBLD Sewer Adequacy - 2/7/2023 SON Cot,„,l RECEIVED
.xoFEB 0 7 2023
Public Health 615 W. Alder Street
Always working for a 5aft r �, r.eaitr.:ei M41s4 ni Co,,nty
415 N 6th Street Bldg 8 Steeltor WA 98584
360-427.9670 or 360•275-4467,extension 400
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 proposes 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 ANDERSON, Carl & Theresa Date- 1-17-2023 c�._namfr‘}y, CPt
1yc2tsaocj e.ariD• 95�27
Mailing Address , '°4,`T1 4sAn City, State,Zip:
Site Address 474 E CHESAPEAKE DR Phone. (530) 515-0551
Parcel Number 12119-53-00035 'ermit Number )ICI 2023 60 I SC/3
Part 2: Sewer System Information
Name of Sewer System HARTSTENE POINTE WATER-SEWER DISTRICT ® Ste Plan attached?
Official use only: Sewer System Manager or Designated Employee is to complete.
0 Now Connection: I have rtrawod the appl.^ants:nformx on and have no:sums*Rh Mas.nn County Pub e.Health arPrr"irQ the carrespondn{t
Mason County Pem*
0 Existing Corwdliat: I have reviewed the appi cants information and have no issues with Masor Ctsunty Pubic:Health approving the
corresponding Mason County Permit
0 !have rerie u.i ttie aptltc:anfS u tomiation and have determined semtr cornec.wn:s Curter vy NOT avatablg to pis property.
0 Pwase and the following hone tionisl on the coreapond•ng Mason County Permit- 'oohnhai)
•
Jeff Palmer. General Manager — _ 1-17-2023
. .SrOen+tuWegee En i,.,,ee • �earavF••Er,01�e--• Uate '
Part 3: Mason County Public Health Review/ Approval !,gT ROVED
..)4SatFsfactnry ❑ Ur.yatisfa:tc;r} ;/� l `r �i�t�3
F��"'�"4'2023 Date
This form may be scanned and available for put iS ZailiiKiMW OMA1%lltititgellaT#iSite-
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