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HomeMy WebLinkAboutBLD Sewer Adequacy - 9/12/2023 MASON CouN Public Health Always working for a safer healthier Mason County 415 N.6th Street, Bldg 8,Shelton WA 98584 —r 360-427-9670 or 3600.275-4467,extension 400 I 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: I .r n n pp �,�-X(�� . < <1 oL�\\ Date: & Mailing Address: o I C)gl4 City, State, Zip: Pain± Dnrkpukl (_`)tl Site Address: �y,l iei[CJ,--kC ,.^kl IJC . Phone: 3(oDTr"C4D - .3.31q Parcel Number: 12217 - S-D - 00090 Permit Number: llIQ24 d l 1-13 Part 2: Sewer System Information Name of Sewer System: d Site Plan attached? Official use only: Sewer System Manager or esignated 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 Pennd. ❑ I have reviewed the applicants information and have determined sewer connection is currently NOT available to this property. Please add the following mndition(s)on the corresponding Mason County Permit: (optional) Printed Name of System Manager)Employee S,mmw of Sy flem Maoegerl Employee Data Pa,,,rtt 3111:: Mason County Public Health Review/Approval satisfactory ❑ Unsatisfactory I v Signature of Envimninhintal Health Specialist Date This form may be scanned and available for public view on the Mason County Web Site. R.SED+anaRols �11D%) 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 9/12/23 PARCEL# 12217-50-00080 SITE ADDRESS 1431 E Old Ranch Rd. 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)lLGIL SIGNATURE 4 40, A COPY OF THE CONSTRUCTION SITE PLAN MUST ACCOMPANY THIS APPLICATION. ------------------------------------------------------------------------------------------------------- FOR OFFICE USE: Connect Fee$12.179.72 Date 9/12/23 Receipt# 1�7 (q. !. q Grinder Pump _Date Receipt# Building Permit# Date Issued Date Final 'Please notify ourdepartment 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.