HomeMy WebLinkAboutBLD Sewer Adequacy - 10/26/2020 (2) .agON Couiv
Public Health 1'14so
Ahvays woddng for a 0-fwrhmatithier Masan County rV Co.UTIJ)r/y,
415 N.61h Sbeet,Btdg B.Shehon WA9MU
3 1275670 or 275 167,evtemlon 100
Application for Determination of Sewer Adequacy
Instructions:
1.Complete Pad 1 of application. Permit number maybe 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 Heaah 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: J&J Development, LLC Date: 10/26/2020
Mailing Address: PO Box 623 City,State,zip: Budey, WA 98322
Sae Address: Block 36, Lot 4 Phone: 253-20U136
Parcel Number 12220-50-36004 Permit Number.
Part 2: Sewer System Information
Name of Sewer System: NBC ae Plan adachedl
Official use only: Sewer System Manager w Dasigrmrerl Employee Is to complete,
Ll N.CorwcWn: ;have revift.wkca.i,d rrOton am taw no trim Mama canes Pudic t rmaPpvvNa nw cwtaWaN^✓2
lC Macon county Pom t
❑ Fadafi,q Corms tim: lhrve,.ww.ed are alpf®rib irdar,mtion a,d lawm®xaswim EYmn Courly PWic VbaM epgwirg tla
mmaPo,M,q Macon C.unry PemK
❑ thaver.vbxadve.Wicarts tonanlhaw6a or. avermmaUbn®cvm,ly NOT euaibW bnva gapxrry.
X1 Plmw.Wth.W +'W con N.)—flao amaidb,Mama Co Pana(opb'm1.1)
Michele Remmen �I� �l ,lYVl 10/26/20
P�a..e ran.dsymm wmaen[mgmw sa....asyv..Ma,.maeadoaa. mm
Part 3: Mason County Public Health Review/Approval
❑ Satisfactory ❑ Unsatisfactory
sigroaaadanmrmirroma Naadrs'daga Data
This form maybe scanned and available for public view on the Mason County Web Site.
aenanraacas
APPLICATION FOR
SEWER UTILITY SERVICE
MASON COUNTY
UTILITIES & WASTE MANAGEMENT
100 W PUBLIC WORKS DRIVE- P O BOX 578
SHELTON, WASSHINGTON 98584 (360) 427-9670 ext 207, 283, 566
DATE 4 1 I UI� �5/21l�
PARCEL# W• 5 �n1n(�'!MA I G
SITE ADDRESS wA
OWNER NAME
BILLING ADDRESS -
�,l�Pc
ANTICIPATED DATE DATE FOR SERVICE TO BEGIN
I agree to the terms and Conditions of the Mason County Codes and/or
Resolutions. (Copy available upon request.)
SIGNATURE /U�l✓{,�-`/
A COPY OF CONSTRUCTION SITE PLAN MUST ACCOMPANY THIS
APPLICATION.
--------------------------------------------'----- -
�.
FOROFFICE OSE:
Connect Fee ),.f�,9�•W� Date4 lS Receipt#
Grinder Pump Date Receipt#
vaeant Lat Fee Effectiw Monthly sewer Rate Effective
Euilding Permit#B-OWUI'(�ISO�Date Issued Date Final
MASON COUNTY PUBLIC WORKS
)(Sewer ❑ Water Permit
Permit No. - 1 ILI Date A 1' 2 Owner
Q
Contractor
Job Description
Job Location Alm 1,6 A- V594
Inspected By Approved for Cover
Date
Remarks
Applicant Must Call
Utilities & Waste Management Issued By
For Required Inspection
360-427-9670 Post this card in a conspicuous place
Ext. 652 at Front of Premises