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HomeMy WebLinkAboutBLD Sewer Adequacy - 9/12/2023 4\)' %)%1 I< 4 A,d �t ,U Vr p ,j� L / 20 Cd,(* J Mason coy23I I]Utilities Co ,� SEP 1 •1� 11013 415 N.BTH STREET,BLDG 8,S LTON VY I;cP7A/ SON O V N 1 i SHELTON:380-427-': .,_ ..C/VED C$ 'v ' NITY SERVICES BELFAIR:380-275-4487,EXT.400 " J` p r ELMA:380-482-5289,Da.400 Sul:ng.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,Slte 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 i � Applicant:4 ,G,/ "Al,Celt/et'i/ t' Date: 7 r//- 2.3 Mailing Address: j i ` j9 id City,State,Zip:hint /e 1' ii./ liffP O,SiteAddress:yl��i Lj '/��.�/y Phone: 0✓ yy®-f/2, - Jo/i.n II f3./ Parcel Number. 1� _ )-(1 -i`-1-L✓0 c)t) _ Permit Number zn23 O ?5 Part 2: Sewer System Information Name of Sewer System: ;1 y ❑Slte 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 Courtly 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) /,,,,:::)______ Printed Name of System Manager!Employee Signature of System Manager!Employee Dale Part 3: Mason County Public Health Review/Approval (2 3 Satisfactory ❑ Unsatisfactory I $,,, Signature of Emlronm ntal Health Spedsllst Date This form may be scanned and available for public view on the Mason County Web Site. REVISED 1,2/2017 CLu'>f - of t ,_at_ -tz NA._G._I\.tx--1(ci-Lkat c t n .1. S(At 3 Lctf r. r\Q- t;-' -{-t,"uikt . J2,ra.cu I . -2Cn lc C�' pe rYvo f c i_1_-k-r v Belfair Mixed Use Zoning EH APPROVED Setbacks as required by Building Code Rhonda Thompson 10/25/2023 Public sewer and water ICY r 0 c JJ I ' 10/25/2023 APPROVED MASON COUNTY DCD PLANNING wOTT RUEMAICP J` ' -'- Digitally — sooa Rudy signed by Scott Ruedy 90014 I