HomeMy WebLinkAboutBLD Sewer Adequacy - 7/24/2023 I
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Application for Determination of Sewer Adequacy
Instructions:
1.Complete Pad 1 of application. Pelmil 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 fw approval.
3.Submit completed application and information to Pernft Center or Mason County Public Health for review.
NOTE:You must aupply the System Manager with a site plan for the projec%showing all existing or proposed
sewer components and lines in relation to proposed development and property.
Part 1:Applicant I Parcel Information
Applicant Sam Martin,Agent for Lermair Northwest,Inc Date: 7/24/2023
Mailing Address: 33455 6th Ave S,Unit I-B city,State,Zip: Federal Way,WA,98003
Site Address: 296NEOhwMrindx Ph. (253)294IMI
Parcel Number. 123M 514110% Permit Number: LI LI)O�V �DOI��
Part 2:Sewer System Information
Name of Sewsr Syslem: adfair l� Site Plan attached?
OMNafuseonly. Sewer System Manager or Designated Employee is to complete.
Rr Maw Chwacron: I haw rawnwhl Ne app6rsMa Nbrmation ac haw m Imuer Hah Mec County Public Health a;,xcac ,Ne wnmpmMin9
New County Peron.
❑ Q'ahp Connec6ort new reviewed ew eppFrenk Mlamaeon an0 haw no lmumwith Mown Coumy Public NeaHN eppoNre Its
oan avers g Mmn County PemA.
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sr Pleas acc ale hunwhae caMNon(e)m en eamapoMe g Mawr county Pith t toruchist
Must meet all Mason County design and construction standards.must pay all fees
including:connection fee with permit and ins 'on V=&d Latecomers charge BD .
Richard Dickinson 8/4Y23
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Part 3: Mason County Public Health Review/Approval
$atisfaaory ❑ Unsabstactory Y�TY�P21"�W/ 3 ' 1 yl v I
l sbrauaed. =+,t Sped7JLjD .
This form may be scanned and available for public view on the Mason County web Site.
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