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Home My WebLink AboutBLD Sewer Adequacy - 3/1/2023 / c / VET 00N--COUP' MAR tis- ?� 6,5 vV , 2,23 Public . , 0 Health • 4/de s r tree! Always working for a safer • 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 ' ). `'°1EITA L. Instructions: HEALTH 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: KINCl/KNUDSON, Don/Kelly Date: 2-27-2023 Mailing Address: 1607 BONNEY AVE City,State,Zip: SUMNER WA 98390-2170 Site Address: 640 E PITCAIRN PL Phone: (253) 224-2329 Parcel Number: 12119-50-00145 Permit Number: Part 2: Sewer System Information Name of Sewer System: HARTSTENE POINTE WATER-SEWER DISTRICT ❑ 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. El 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) . rh,— ) Jeff Palmer, General Manager — ^.r.-,a 2-27-2023 Printed Name of System Manager/Employee Sig ure of System Manager/Employee Date P : Mason County Public Health Review!Approval r,...5 `„ -5 atisfactory ❑ Unsatisfactory •&/'?"\52,0/ 4(1 1 ) 13 ii- Signature of Environmental He th Specialst Date This form may be scanned and available for public view on the Mason County Web Site. RLVISLO 1048'2015