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Public f-vcr Health
Always working for a safer i healthier Mason County
415 N.6th Street,Bldg 8,Shelton 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 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/Parcel Information
Applicant: MTT Construction, LLC Date: 2-27-2023
Mailing Address: 16000 Christensen Rd. Suite 150 City, State,Zip: Tukwila,WA 98188
Site Address: None Phone: 253-583-6062
Parcel Number: 42012110000 Permit Number:
Part 2: Sewer System Information
Name of Sewer System: City of Shelton ❑ Site Plan attached?
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 have reviewed the applicants information and have determined sewer connection is currently NOT available to this property.
® Please add the following condition(s)on the corresponding Mason County Permit: (optional)
Project shall annex to the City of Shelton prior to recording of the final subdivision plat. Site construction plans shall
be prepared to City Standards and submitted to the City for civil review, bonding, permit issuance, and inspection.
Jay Harris / 2-27-2023
Printed Name of System Manager/Employee Signa ure ce erh an r/E Date
Part 3: Mason County Public Health Review/Approval ��� /�3 J�
Satisfactory ❑ Unsatisfactory F1),
Signature of Environme tal Health Specialist Date
This form may be scanned and available for public view on the Mason County Web Site.
REVISED 1Ci28,2015