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Home My WebLink AboutBLD Sewer Adequacy - 9/12/2023 19AyON COUNT! Public*Health Always working for a safer healthier Mason County 415 N.6th Street,Sldg 8, Shelton WA 98584 360427-9670 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 1 p Applicant: �ff.��x..,,�,ono",nv,iL y�a „ fl cA sM� Date: t l l o�la Mailing Address: NU g� I(7c�-A City, State, Zip: �ftl-¢ Site Address: rill F_ ..e 0 C6J ''' n ��+++� �n��p� Phone: 31nC1 31-kD"- 331�' Parcel Number: I a `J b s I Q - — /CSEf o \ - Permit Number: I`"ncja Id 2a23 •G I l7 Part 2: Sewer System Inform-a�'tAtio- Name of Sewer System: ❑ Site Plan attached? Official use only: Sewer System Manager or Designated Employee is to complete. New Connection: I have reviewed Me applicants information and have no issues with Mason County Public Health approving the coresponding Mason County Pernd. ❑ Existing Connection: I have reviewed the applicants information and have no issues with Mason County Public Health approving the coresponding Mason County Pernft. ❑ 1 have reviewed the applicants information and have determined sewer connection is wrrendy NOT available to this property. Please add the following GAG fco,n�ddion(<n Mwaponding Mason County Permit: (opaorrell > j92>C, 7-0 n Pmted Name of Syefem Manegerl Employee Signature of System Managerl Employee Due Part 3: Mason County Public Health Review/Approval �, I I I �Z3 Satisfactory ❑ Unsatisfactory Signature of Envi�OpmentaI Health 'a'st Date This form may be scanned and available for public view on the Mason County Web Site. Redseo t.ol 8(a00LO 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 9112/23 PARCEL# 12218-50-00006 SITE ADDRESS 290 E Sterling Dr. Allyn WA 98524 OWNER NAME Pioneer Builders Inc BILLING ADDRESS PO Box 1094 Port Orchard We 98366 1 agree to the terms and conditions of the Mason County Codes and/or Resolutions (Copy available upon request) ✓ SIGNATURE f� ( lL.k A COPY OFTH CONSTRUCTION SITE PLAN MUST ACCOMPANY THIS APPLICATION. FOR OFFICE USE: Connect Fee$12.179.72 Data 9112123 Receipt# _7 0/aS Grinder Pump Date Receipt# Building Permit# 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.