HomeMy WebLinkAboutBLD Sewer Adequacy - 5/15/2023 400457
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Public� � ��Health
Always working for a safer i 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: Sam Martin,Agent for Lennar Northest 5/15/23
Date:
Mailing Address: 33455 6th Ave S, Unit 1-B City,State,Zip: Federal Way,WA 98003
Site Address: 180 NE Belfair Station 253-294-1322
Phone:
Parcel Number: 12328-51-00013 k1 20E3- ()Cal 4
Permit Number:
Part 2: Sewer System Information
NameBelfair Sewer District
of Sewer System:
• ® 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)
Must meet all Mason County design and construction standards, must pay all fees
including: connection fee with permit and inspection fee, and Latecomers charge (TBD).
Richard Dickinson
--- 5/23/23
Printed Name of System Manager!Employee Signature of System Manager/Employee Date
Part 3: Mason County Public Health Review/Approval ,J�
Satisfactory Unsatisfactory❑ //0-1
Signature o vironmental Health Specialist Date
This form may be scanned and available for public view on the Mason County Web Site.
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