HomeMy WebLinkAboutBLD Sewer Adequacy - 11/29/2023 MASON CO(7NT�
PublicHealth
Always working for a safer healthier Mason County
415 N.M great,Bldg 8,Shelton WA98584
360 427-9670 or 3W2754467,extension 400
Application for Determination of Sewer Adequacy
Instructions:
1. Complete Part 1 of application Permit number may be added at later date.
2.Take application, SHe 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/Parcel Information
Applicant: BRYNN&STEPHEN BLACK Date: 11-29-2023
Mailing Address: 5734 SW DOWNS VIEW CT City,State,Zip: PORTLAND OR 97221-1260
Site Address: 453 E CHESAPEAKE DR Phone: (503)577-4410 (503)927-7867
Parcel Number: 12119-53-00042 Permit Number:
Part 2: Sewer System Information
Name of Sewer System: HARTSTENE POINTE WATER-SEWER DISTRICT ❑ Site Plan attached?
OMcial use only: Sewer System Manager"Deslgmted Employee is to complete.
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Mason County Permit
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Jeff Palmer, General Manager + , r 11-29-2023
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PZrt11 3: Mason County Public Health Review/ApprovalcYM t /'7/27 -y
Satisfactory ❑ Unsatisfactory I
SereWre ofE Nmnmentel HaeM Specialist Date
This form may be sunned and"enable for public view on the Mason County Weir Site.
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