HomeMy WebLinkAboutBLD Sewer Adequacy - 4/25/2023 400451
415 N.BTH STREET,BLDG e,SHELTON M Waal
MASON COUNTY SHELTON.laedn- 0.EXT.eoo
COMMUNITY SERVICES 9ELFNR:W271 44e7,Exr 400
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Application for Determination of Sewer Adequacy
Instructions:
1.Complete Pad 1 of application. Permit number may be added at later data
2.Take application,Site plan,and any other associated Information wiM the proposed development Mahe 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,Shoveling all existing or proposed
smBr components and lines In relation to proposed development and property.
Part 1:Applicant/Parcel Information
Atli Sam Martin,Agent for Ixrmar Northwest,Inc Dale: 4/25/2023
Mailing Addmaa: 3M55Mh Aw S.Uaitl-B,FMeral Wav98W3 City,State,Zip. Federal Way WA 98003
Sint address'. 161 HE Belralr Station Phone. (253)294-113322
Parcel Number: IM2&SIGOW Permit Number. {/ic.1�y;,a12J� ()I`♦_I
Part 2: Sewer System Information
Name of Sewer System: Belrair ® Site Plan attached?
Official use only: Sewer System Manager oroeslgnared Employee is to complete.
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Must meet all Mason County design and mnslruclion standards, must pay all fees
including:connection fee with permit and inspection fee,and Latecomers charge(TED).
Richard Dickinson 12"� c -3 5/4/23
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Pa[[y133:Mason County Public Health Review?Approval
atisfactory ❑ Unsatisfactory
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This form may be scanned and available for public view on the Mason County Web Site.