HomeMy WebLinkAboutBLD Sewer Adequacy - 12/27/2023 MASON COUr\rl,P
Public Health
Always working for a safer healthier Mason County
415 N.6th seen.Bldg 8,Shelton WA 96584
360-427-9670 or 360-2753467. .sl.ns,.n 400
Application for Determination of Sewer Adequacy
Instructions:
1.Complete Part t 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 infornation 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: CHANG Judy Data: 12-27-2023
Mailing Address: 9215 N FORTUNE AVE Ciry, Stata,Zip: PORTLAND OR 97203-2673
Site Address: 108 E LIBERTY RD Phone: (971)533-0773
Parcel Number 12119-53-00069 Permit Number.
Part 2:Sewer System Information
Name of Sewer System: HARTSTENE POINTE WATER-SEWER DISTRICT ❑ Site Plan attached?
OOlCialusecnty: Sewer System Manager or Designated Employee Is to complete.
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Jeff Palmer, General Manager - r 1 - 12-27-2023
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Part
3: Mason County Public Health Review/Approval
Satisfactory ❑ Unsatisfactory I "y
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This form may be scanned and available for public view on the Mason County Web SRO.
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