HomeMy WebLinkAboutBLD2021-01746 - BLD CD Environmental Health Review - 10/13/2021 B T— qto
Pubfici& Health
Always working for a safer (;healthier Mason County
415 N.Sun Street,Bldg 8,Shelton WA 98584
360-427-9670 or 360-275-4467,extension 400
Application for Determination of Sewer Adequacy
Instructions: L(, ACLLX4. * 4- Op It
I.Complete Part 1 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 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: j2( I P,h Np! 'R / O D cStT Data.
Mailing Address: /.7"z -5 E 7/'0r 5E-i e e L City, State,zip: AJe lullLS t.2E.y (U * ,e 6
Site Address:`7.3`fe E eq�g& ev;ew l j?.Q Phone:
�}ZS-(A & 1 -5�?/ 8
Parcel Number. 1,;Fa 2 9 -/ 3 - o0o Sa Permit Number.
Part 2: Sewer System Information '`CIS
of Sewer System: r'f 1 ,a CRSt v 4 t i51ySite Plan attached?
Official use only: Sewer System Manager or Designated Employee is to complete.
❑ New Connection: I have reviewed the applicants Informatlon and have no issues win Mason County Public Health approving the corresponding
Mason County Permit
® Evsting Connecllom I have reviewed the applicants Information and have no leaves with Mason County Public HeaN1 approving the
wrrespondire Mason county Pemat.
1 have reviewed the applicants treormatbn and have delermined sewer connection is wrraney NOT available to this property.
.� Please add the following wndition(s)on the woesponding Mason County PWffft/ (opsonaq
C�(OYCo;o.eG /
/.Z ZO
Prated Nemeof System Mewed Employee Slgnaeae or Syswn Manager/Fmpkyea Date
Part 3: Mason County Public Health Review/Approval
Satisfactory ❑ Unsatisfactory r
Signature of En mental Health ap-�eyy����t I� Date
"ra* l -S
This form may be scanned and available for public view on the Mason County Web Site.
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