HomeMy WebLinkAboutBLD Sewer Adequacy - 6/28/2021 (2) . bl C➢1V, 4:ay C)j�l��
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Always wol king for a safci @ healthier Masan Cell n ty
415 N.(t1h Streel,Bldg 6,Shelton VM 90564
360-427-0670 or 360-275 4467,extension 400
Application for Determination of Sewer Adequacy
Instructions; -
1. Complete Part I of application. Permit number may be added at later date.
2.Take application,Site plan,and any other associated information will)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 WVI Information
Applicant: CA II IRV,-e.IY11ott/1 Dale
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MailingAddress: 19oY�', (,. 91,2sC City, State,zip: pt —t7t 'lor YA 9'Q 366
Site Address: � � r-m It-1 J-0Z. Phone: -Z�- J) -nI -S-7Rq
Parcel Number `7i7,16--7S^ Permit Number: ,SW7Z : L- 00
Part 2: Sewer System Information
Name of Sewer System: N o Mn 13A &`Sd-Plan attached?
OHJc7a1 use only: Sewer System Manager or Designated Employee is to complete.
❑ N"ceersou : Ihavo revrowed lho epplitanls information and M1ava nn lssveewilh Mason County Publk Hoaah approving the correspwrding -
Mason county Parma. -
0 Existing C.n.alon: I M1ava rmlevmtl Iha opplkanls kiamalbn and have rw Issues with Mason Gowdy RrbL•c HeaiO npprovkg the
wvespondihhg Meson County Permit ,
-® I have revkwetl the applicants intonation and have determined sewer osnre ion Is cannily NOT available to IMB present.
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Par ason County Public Health Review/Approval .7 ' tz �Zf
Satisfactory ❑ Linsmisfaclory
Synalure of Envi,.el lental Health Specialist dale
This form may be scanned and available for public view ou the Mason County Web Sits.
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Vanguard Laboratory
263S Parkmont Cane SW. Suite A
Olympia VVA98502
360-967-7010
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