HomeMy WebLinkAboutBLD Sewer Adequacy - 11/2/2021 (2) 101AgON COOry�hh
Public Health
Always working for fah
alMler Mason County
415 N.eth Street.Bldg S,Shelton WA 98584
360427-9670 or 360-275.4467,extension 400
Application for Determination of Sewer Adequacy
Instructions:
t tompleu Pefr-7 of eppllaaUon. Permit number maybe added at later date.
2;1(tak'Sp(kI1611 bn,Site plan,and any other associated Information with the proposed development to the Sewer
SystemtMenagenor, Designated Employee for approval.
S.Subma completed'applice0on and Information to Permit Center or Meson County Public Health for review. -
. .MDTE:)4u must supply:the System Manager with a site plan for the project,showing all ezlating or proposed
sarearaomponents and lines In relation to proposed development and property.
Pert 1:Applicant I Parcel Information
Applicant: CeE TVA!SFi(/ D6te: z�z
Mailing Address: 26 6Q- 3 7n City,State,zip: 18 /6 ,T, 2d 9Asa.9
Site Address: gap N9 77�rE RZ '3rn Phone: ,,,/��,
Parcel Number. /Z"329 - a/2 — 4a0 2 o Permit Number. CO r L0 ZZ
Part 2: Sewer System Information e-✓
Name of Sewer System::a (-G,,r E Site Plan aa0ChM4
OMrclal use only: Sewer System Manager or Designated Employee Is to complete.
AID New CanneNon: I have revkevd V,e appUwoW oloonabon eM have no lsweewith Mason CWMy ftNc Heats awrOwng UM mnepondlna
Mesas county P.MI.
❑ EaWlnp GonneNan: I ...ly PrenE the appecend NlamMUonaM have rolaww wlP Mown County Public HeelN epprevNp tie
wnepondlmB Maps CounlY Parent.
❑ Il se Tawad Aa eponceno.1n1onoun neM M.delamJnad eaew Nm.eHp la ounnll,NOT nveHebk to W.Rows..
Reese add aw ease,coMaon(e)on on,cone/aynMlos Mayan Camyry Permit(opllanaU
VNnea Nmro Nerelem MeiopeN Empbyee 5pnew,eg9yebm Abngm/Emybyaa WM
Part 3: Mason County Public Health Review/Approval
Satisfactory ❑ Unsatisfactory
s nmonwl HaaM spec" Del,
This form may be scanned and available for public view on the Mason County Web Site.
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