HomeMy WebLinkAboutBLD Sewer Adequacy - 5/15/2023 400465
�ASoN COUyy�f'
Public Health
Always workinuf for a tw er healthier Mason County
415 N.61h Street,13W98,Shellon WA98584
MOA27-9810 or 360-2754467,edW.I.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 Lenom Northest Date: 5115123
Mailing Address: 334556th Ave S, Unit 1-6 City,Stale,Zip: Federal Way,WA 98003
Site Address: 121 NE RkJgetop Crossing Phone: 253-294-1322
Parcel Number: 12328-51-00021 Permit Number: "31d2623- Olr-153
Part 2: Sewer System Information L.0} 2
Name of Sewer System: Belfair Sewer District ® Site Plan attached?
Official use only: Sewer System Manager or Designated Employee is to complete.
0 New ConnMim: I have mimed the applicants information and haw no lvauea with Mann County Public Health approwry NacanwriorEYp
Macon County Pwat.
❑ Ealang Conrecllan: I have reNawed Neepplcents waranalion and hew,no lial an Mwm count,Public Health appoving the
corresponding Meson causes Pal
❑ I he.revrwN the applicants Information and haw determined server contraction is seemly NOT evelkbM b This gol
® Please rand the klbwiq canditipala)on the corresponding Mason County Permit.(opl"
Must meet all Mason County design and construction standards, must pay all fees
including:connection fee with permit and inspection fee,aanndd'Latecomers charge(TBD).
Richard Dickinson �j�-- —, 6/12/23
RMMNemeasnum Masewlempbres agwlweaswem Msepm Employes oNe
Pa : Mason County Public Health Review/Approval
Satisfactory ❑ Unsatisfactory a/ V 1 o 6 t?—.�)
Signf� MEnvNon eel Health apetlelMl. r p,Ma
-N'CU'lc� I ltiS a_'`ar`iVj�� Jul
This form may be scanned and available for public viewed the Mason County Web Site.