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HomeMy WebLinkAboutBLD Sewer Adequacy - 6/20/2023 coN Cori Public Health 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 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: Stephen Harris Date: 6/20/2023 Mailing Address: 945 Eaglecrest PI City,State,Zip: Port Orchard, WA 98366 Site Address: 61 NE Daybreak Dr. Belfair WA 98528 Phone: 360-979-9057 Parcel Number: 12332-52-00003 Permit Number: BLD2023-00685 Part 2: Sewer System Information Name of Sewer System: Beflair Sewer ® 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) Richard Dickinson / ' 6/20/2023 Printed Namo of System Manager/Employee Signature of System Manager/Employee Date Part 3: Mason County Public Health Review/Approval L 1/d �� 0, Satisfactory ❑ Unsatisfactory '�' �'7f��r Signature of Environm tat Health Specialist Date This form may be scanned and available for public view on the Mason County Web Site. REVISED le/ta12015 APPLICATION FOR SEWER UTILITY SERVICE MASON COUNTY UTILITIES & WASTE MANAGEMENT 100 W. PUBLIC WORKS DR. SHELTON WA, 98584 360-427-9670 X 566 mremmen@masoncountywa.gov DATE 6/20/2023 PARCEL# 12332-52-00003 SITE ADDRESS 61 NE Daybreak Dr. Belfair WA 98528 OWNER NAME Stephen Harris BILLING ADDRESS 945 Eaglecrest PI Port Orchard WA 98366 I agree to the terms and conditions of the Mason County Codes and/or Resolutions (Copy available upon request) SIGNATURE C4 ( A COPY OF THE CONSTRUCTION SITE PLAN MUST ACCOMPANY THIS APPLICATION. FOR OFFICE USE: Connect Fee 11,300 Date 6/20/2023 Receipt U \ C� Grinder Pump Date Receipt# Building Permit## BLD2023-00685 Date Issued Date Final *Please notify our department when the final inspection has been completed so your sewer account can be activated.You are responsible for billing as soon as construction has been completed.