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HomeMy WebLinkAboutBLD Sewer Adequacy - 5/4/2023 19yA.50N C0rJ'V vE° Public Health 1..� %I\ 5 to. Always working for a safer healthier Nasonfnunty Ma VV\ttle 415N.61h Street,Bldg 9,ShelumM95594 Masrop�pl?pt� 96042T-96]0 or3 2]5-446).extension 400 Application for Determination of Sewer Adequacy InsWctions: 1.Complete Part 1 of applimli,o 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 far approval. 3.Submit completed application and Information to Permit Center or Mason County Public Health for review. NOTE:You must supply Me 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 Info aption Applicant � 1I C ,t C Date: Mailing Address: \RZnu ��� 4JC CI C City,State,Zip'2 U 110 rir� & ,57 c, Site Address: 7 1 fta(D �-Il2(1 C't Phone: Parcel Number: t 22Z-�(78'c/On 7�r Permit Number Part 2: Sewer System Information Name of Sewer System; r `'f'Lt j ©�Site Plan atlached7 Official use only: Sewer System Mona or Desitim ed Employee u W complete. i „� New GonnecYwr lluwrevimvaO V.e apprinm lnlun®YoneM twe ru iwrs rM Mewn Counb PWkc HeelN epgovlw the cwRapoMnB Meson C unb Pemvl. ❑ Exmrgc.0n l: laeK ieNawed Me aryYunb lntorirehn vMlw+amiaueawiN Maam Cwnty PWlq Halth ePF�'im arc runespondim Meson cwilb Pemit. ❑ Itwe nevi me aPrGranM lManMlim aid tore aea+nt�al sewer osi tl iso 01 NOT avai1sWmlths R^PaRF ia Mine nw/ wswwlewMNw(a) mer.,oniir,Mews couNy Pamc(Wamag Ze 'r 'new- r _' c�5-oY-ham %Mw NwaolSWw^Ya�varE,ThYr^ SiPeve YSraem MaS^�re�^fMe'+ D°' 'l Pal Mason County Public Health Review/Approval pl r� �.r . `-1 I Satisfactory ❑ Unsatisfactory �'�(� - Si9neWreHnINSped/Xl2G� Deb Wtt�IP�.�11iZa/l r!_/JI This form may be scanned and available for public view on the Mason County Web Site. pE�e�rwp e i y„ "1AVi- 2, I �j