HomeMy WebLinkAboutBLD Sewer Adequacy - 6/1/2016 MASON COr!/v�,Y
Public Health MAY ' 2016
Always working for a safer healthier Mason County
e16 N.6th Street.Bldg 8,Shelton WA 985M
360-427-9670 or J80-275J 167.extension 000
Application for Determination of Sewer Adequacy
Instructions:
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Part t:Applicant I ParCeI Information
Applicant r��hC�� V A'YJr�11AA Date:
Mading Address. i} V I O S�`rn�-e. �'/nk� 'J city,Slow /zip: t�1\`C1�t� t�.)c) °�`(i52
Site Address'. U��\ Spa f_ K.. ' ,� Phone:
• -ParcelNumber � 222f� - °.3 - t.:iA Permit Number •t
Part 2: Sewer System Information 1 III
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Name of Sewer System: ^ r t � � r 11._.\ _H .al Slte Plan attached?
official use only: Sewer System Manager or Designated Employee Is to complete.
New Connecaoo: I have revewed Na applbnb lnlormatwn and have no bauea with Mason County Public Health ap scr irq the cooreepoMina
Mason County Permit
❑ Enaong connecter, I have reviewed me apWtrz^n mtormauon and have in,—with Mason Count,PuW'c Health approving the
w Wirds,Mason county Parma
❑ I have reversed are appllunts reformation and have deMrminad serer connection ve currently NOT evadable m this propeM-
%eas add Me Moxin9 wed 1bMV on Me corresponding Mason
Co ry Permit.(oppdonegj ,J_ -
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Part 3: aeon County Public Health Review/Approval
S factory ❑ Unsatisfactory Z
s named E.4ninevessal Heald Speealiat o
This form may be scanned and available for public view on the Mason County Web Site.
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