HomeMy WebLinkAboutBLD Sewer Adequacy - 5/12/2021 i I
MASON CoUN�� 67g MA !? 2021
PublicHealth W Alaergtroef
Always working for a safer healthier Mason County
415 N.6th Street,Bldg 8,Shelton M 98584 ENVIRONMENTAL
360-427-9670 or 360-275-4467,estenslon 400 _
Application for Determination of Sewer Adequacy F7.r1LTH
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 I Parcel Information
Applicant: sae.b'� �WSTS Date: y11A I�21 n
Mailing Address: PO go-& 106L City,State,Zip: /dkg-6 klk' T-OO&
Site Address: Ito E - <cu Nu. PL,�WwM�tone:7 e'1—Z:4 4-31l
Parcel Number 17tiK—SZ-000It Permit Number
Part 2: Sewer System Information
Name of Sewer System: ❑ Site Plan attached?
oflicialuseonly. Sesser System Manager or Designated Employee is to complete.
New uctlon'. I have ievbwetl the appli®r,b in/amedon anti M1eva no issues wiM Meson Count'Pl&Ik HOWh apprwlrp the wrreapandliq
Mesonn County Perna.
❑ Escling Connectlon: I hive reviewed the appllcenla lnformatlon and new no Issues with Meson County Public HeWh applovthg the
mrn spdnding Mein County Permit
❑ I have mvlewitheapplicental^fortretlm and havedetermined sawarm^nacdm Is onbilly NOT available to this PaWit,
❑ Please add are fwavin9 condNon(s)on the mnespondln Mason County Penrt(behone9
�Jes C
w G � )eons AM44�
l
PMkd Neme65ysbm ManapM Empbyx Sib^eMe dByWm Manage Emp" Ala
Part 3:son County Public Health Reviewl Approval
1 Satisfactory ❑ Unsatisfactory 11. �Qfly 1,
tignelure M En ' nreMel Health S I' Date
3 1 lAI
r"IL a (SQ _
1 This form may be scanned and available for public view on the Mason County Web Site.
1 eeviseP,Pxaams
l
i
i