HomeMy WebLinkAboutBLD Sewer Adequacy - 8/2/2024 cC' II
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Public Health
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415 N.site Street,Mg S,SheMon WA8955a FCF/
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Application for Determination of Sewer Adequacy
bstiuctlons:
1.CoroPleb Pert 1 aAdPHomon. Permk number may be added at later data.
2 Take apprioaaon,Site plan,end any other aesoaated irdolmatbn aft the proposed davelopmarrtto the Seller
System Manager or Oeagnatsd Employee for approwl.
3.Submk mmplarod application and information to Pevna Center or Mason County Public Health far review
NOTE:You must supply the System Manager vAth a site plan for the project,shoWna All existing or proposed
sewer components and lines In Mallon As proposed development and property.
Part 1:Applicant/Pa [Information
AppI.m,-Tlas� AS I qA(Wiy% MOM Dab:
Maur,Add.CAI CM.Sbfe,rZirP�:
Sib Address: •TII)�r�1�1s _p Na�lVs 1/ytVV W Phone: -N7)
Parcel Number: 1011 ' IS�D W�i PermR Number._I,Jt.Dp10��1 _ W-1 V
Part 2: Sewer System Information
Name of Sewer Syabm:' °IY tff`h2 PIt1'fr W1.'f2Y —.sc.,aa• ❑ She Pia.afaddy
Ofaclafuseonfy: Sewer Sysem Mwugaror DesignoWdEmployee IsWp pied.
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Pa. rP: Mason County Public Health Review/Approval ` a�zoh,,-j
41pf,L,Sadstaclury ❑ urwatisfactory
Soon.ofEnsuoranaldlIbaM SPwelid ple
This form may be sunned and available for public view on the Mason County Web Site.
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