HomeMy WebLinkAboutBLD Sewer Adequacy - 4/13/2023 c -1D52
Public .. Health APR 13 L,3
Always working for a safer heallhi�r Mason County
415 N.6th Street.Bldg 8.Shelton WA 98584 615 W. Alder Street
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 formation r�
Applicant: D�1 rIL ( et,c Z ll l6{ .SOYA Date: i oL li C
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Mailing Address:-PO (' l� {- City,State,Zip:Zi a Latta. ` �1.J 14 9 g315
Site Addresson� �, W.QS -1 �l.J'r . n. Phone: __ _ g d .22_
Parcel Number 19 —CID—e0057 Permit Number:
Part 2: Sewer System Information Name of Sewer System. NO(l4. (5ay/Cc..e, TAW- ❑ Site Plan attached?
Official use only: Sewer System Manager or Designated Employee is to complete.
[a 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 Puhllc Health approving the
corresponding Mason County Permit.
0 I have reviewed the applicants information and have determined sewer connection is currently NOT available to this property.
P.r Please add the iollowirig conditions)on the corresponding Mason County Permit:(optional)
tj011ow f'to4on Cnu s sete Des*x Cilnskttchon 5 rd5. 5c tale
l fections WrP rw\o: er. CcC, Cho(y5 ale, SIG L5G.9-4 •
Tv5 aQs 9,44424 t.,�- 1z.121/LZMimed memo of 5yslem Manemen Employee Sr�inaor Sawn Managod Employee Gate
Part 3: Mason County Public Health Review/Approval
satisfactory ❑ Unsatisfactory c'N(Y)
Signature of Environm tat Health Specialist Date
This form may be scanned and available for public view on the Mason County Web Site.
4 REVISED 10,2ar2.w
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