HomeMy WebLinkAboutBLD Sewer Adequacy - 6/28/2023 11/2,,ON cO1J1V:s
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Public :Health RECEIVED
Always working for a safer i healthier Mason County
415 N.6th Street,Bldg 8,Shelton WA98584 JUN 2 8 2023
360-427-9670 or 360-275-4467,extension 400
615 W. Alder Street
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: Ken Hill Date: 6/26/23
Mailing Address: PO BOX 435 City,State,Zip: Allyn, WA 98524
Site Address: 371 E MADRONA PARKWAY Phone: (503) 888-6979
Parcel Number: 22127-51-00033 Permit Number: BLD2023-00421
Part 2: Sewer System Information
Name of Sewer System: RUSTLEWOOD E1 Site Plan attached?
Official use only: Sewer System Manager or Designated Employee is to complete.
0 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.
El Please add the following condition(s)on the corresponding Mason County Permit: (optional)
Existing utility account must be paid in full($487.41 balance due)prior to issuance of permit.
Richard Dickinson 6/27/23
Printed Name of System Manager/Employee Signature of System Manager/Employee Dale
Part 3: Mason County Public Health Review/Approval eb(3.0 J7 3
)6Satisfactory ❑ Unsatisfactory
Signature of Environ ental Health c4 SpecialistQali4 i Date
4-( -'.' ltd. i
This form may be scanned and available for public view on the Mason County Web Site.
REVISED 1028/2015