HomeMy WebLinkAboutBLD Sewer Adequacy - 8/21/2023 400528
445 N."H STREET,BLOG S.SHELTONNNaaSEa
MASON COUNTY aHELroN:asVP .ExT.4aa T
BEIFNR'ffia.P5N87,IXT.100
COMMUNITY SERVICES El kaaa49ad .W.4W
aiin9wnw.N.anawnuad M411e GmnxmlryHeaaM1 FP Y 27-77%a
Application for Determination of Sewer Adequacy
Instructions:
1.Complete Part 1 of application. Permit number may be added at later dale.
2.Take application,Site plan,and any other associated intonation with the proposed development to the Sevier
System Manager or DEsgneted Employee for approval.
3.Submit completed application and information to permd Center or Mason County Public Health for review.
NOTE:You mustsuppiy the System Manager with a site.plan for the project,showing all existing or proposed
sewer eompments and lines in relation to proposed development and property.
Part 1:Applicant I Parcel Information
Applicant Sam Mazda Agent for l.er nur Northwest,Inc Daley 8/21/2023
Maaing nddrees: 33455 6th Ave S,Unit I-B City,State,Zip: Federal Way WA 98003
SltaAddress: 110NE Olympic Mile phone: (ssa)aa4-1Bu
Panel Nwnber. 12328-51-00137 HS#137 Permit Numlmr. RI �1���07!
Part 2:Sewer System Information
Nameof5eM2r System: MW' Site Plan adaGretl?
OM.sa,,"cMr Sewer System Mannwe DeWgmf dEmpbyeetstacompbfe.
ay Nex LonneWOlc'a
M1eve revkwel NeappY 6Flamalbn sM M1eramierumvwN Marm Ca+MYI'uCllc MealN appavLq fM1a cmreapwwNa
Wa Canty Pa"u
❑ F"Nrq Lmn live IM1eve mtlmw]Neap{acenb MWRAtlm eM Memlgzuea MM Marvel Ceunb PWic Heats WM^r'+N a'e
camponaYg Maven Cw+nH Penns
❑ IM1ewredewM me aa*—'iMametlon and M1sva EaYmircd ea"arm"rtr2u'ie anerat/NOT evaaaEb btnts popery
1 pp Plwr aW th b`nlR melllb+(slman mvapaBlW MiWnCw'aV GemYC IWIbIWI
Must meet II Mason Ceurdy design and construction standards must pay all fees
including:connec0on fee with permit and ins fee,and Latecomers char e D .
Richard Dickinson 9023
�� RMaf Ne,edSNm�NUWsI EnWRe EMraaedErWm MCWm6^W/� UYe
4 Part 3:Mason County Public Health Review/Approval
❑ Sahsfictory, ❑ Unsatisfactory 91praPne erEnNpnaem+IHwM sI<dalla Des
This form may be scanned and available for public view on the Mason County Web Sea.
revamumn