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HomeMy WebLinkAboutBLD Sewer Adequacy - 8/22/2023 AuthenSegn ID:33716790-6840-EE 11-A3F 1-60458DE D 1 B5F LJ co14 cot/ • AUG 2 2 2023 Public Health RECEIVED Always working for a safer(t healthier Mason County 415 N.Gilt Street,Bldg 0,Shelton WA90504 360.427.9670 or 360.275.4407,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 I Parcel Information Applicant: Cameron Jurgensen Date: 8/21/23 Mailing Address: PO Box 791 city,State,Zip:Allyn,WA 98524 Site Address: 790 E North Bay Road,Allyn,WA Phone: 253-380-9250 Parcel Number: 122171400050 Permit Number: Part 2: Sewer System Information Name of Sewer System: L Site Plan attached? Official use only: Sower System Manager or Designated Employee Is to complete. ❑ Now Connection: I havo reviewed the applicants Information end have no Issues with Mason County Public Health approving the corresponding Mason County Permit. Ur/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 doternt ned sower connection Is currently NOT available to Ihls property. d Please add the following condition(s)on the corresponding Mason County Permit:(optional) /c'/P_cLc.e. /1T6 CA-"(4;CIA-.J L.,a01•1c.+ / Q <<u,�l n v,on ✓C '1,, e av'crL4rV- PkS✓+ttS P Printed Name of System Manager/Employee Signature or System Manager!Employee Dale Pa 3: ason County Public Health Review/Approval V500 /70 Satisfactory ElUnsatisfactory Sig alum of Environmental Health Specialist Date This form may be scanned and available for public view on the Mason County Web Site. 4 nwl$Ee Im ousts PR0 VEE MASON�p AU�302023 NN- ENVIR p f p�� N,(ENrAL HEAIrN,