HomeMy WebLinkAboutBLD Sewer Adequacy - 5/31/2023 RECEIVED
MAY 3 1 2023
Mason County Utilities Co.
415 N.6TH STREET,BLDG 8,SHELTON WA 98584
MASON COUNTY
SHELTON:360-427-9670,EXT.400
�l COMMUNITY SERVICES BELFAIR:360-275-4467,EXT.400
r. ` 4� ELMA:360-482-5269,EXT.400
<j;• �' Building,Planning,Environmental Health,Community Health FAX:360-427-7798
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 I Parcel Information _
Applicant: 13,q t2 I .i i� j l T t L../6 L G' j?Nt C./)! Date: `) 3
Mailing Address: 2 7 46 At i J 2 VC) £ i-l) City,State,Zip: PO U 13G) 1,) (-) TN')
Site Address: j,.j C Ll,C=> Phone: c% ("1 6
ci
Parcel Number: .:q ! 2 7 - - D 06, S 7 Permit Number: i� Jd 2023 -(o
Part 2: Sewer System Informa 'on G z3e4 f�l 0 .ti`E,5 ' L C C 0 V j v 0 K • o
pp
Name of Sewer System: t
El Site Plan attached?
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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.
O 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)
. dataerName of System Managed Employee ---Zaraltatt of System Manager/Employee Dale
Part 3: Mason County Public Health Review/Approval 5/T,6,
it]
Satisfactory ❑ Unsatisfactory
ignature of Environmental Health Specialist Date
This form may be scanned and available for public view on the Mason County Web Site.
REVISED 312/2017