HomeMy WebLinkAboutBLD Sewer Adequacy - 3/11/2024 ENVIRONMENTAL �ao�� - �o3a�
HEALTH
N �NSON COUN
r� RECEIVED
Public 'Health MAR 11 "94
Always wadding for a safer healthier Mason County
415 N.fith Street,Bldg 0,Shelton WA 981 E% greet
300427-9670 or 360-275 467,extension 4W
Application for Determination of Sewer Adequacy
Instructions:
1.Complete Part 1 of application. Peril 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 aupply 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 I Parcel Information
Applicant: Ethan GillmvglJared Bashmer Date: 2r272024
Mailing Address: 318391h Ave SW,SuiteA City,Slale,Zip: Puyarup,WA9W73
Site Address: 9B0 E NOM Bay Rd,AByn,WA 98524 Phone- 866.657.4371
Parcel Number: 12217140W70 Permit Number.
Part 2: Sewer System Information
Name of Sewer System: North Bay/Case Inlet (] Site Plan attached?
OflMat use only: Sewer System Manager or Designated Employee Is to complete.
® New Correction: I have reviewed the awliranla inrwmalion and have m lasuee with Meson County Pudic Heaeh appwiN ae cprawd�ding
Macon county Pernil.
❑ EaiaMq Connection: I have reek an apoH nb inMmtk aM Mve m ieeueswb Mason Cw Public Health epptwim aM
mreepotMm9 Masco Count,Peril.
❑ Ihate teview.lheapgitanla ou.nnetion aM hi Manna sw.vre,maddon a mmMt,NOT avaibEk W this pmpeM
® Plnee add the Iolloxin0 mndihm(s)on use cae,rdaim Maven cause,Permit ropliver
Must meet all Mason County design and construction standards, must pay all fees including:
connection fee with permit& inspection fee, a grinder Kp is required.
Richard Dickinson 2/27/24
PnMd Nwnadsyrwn M.uven ampge. sial.luadsyawn Mwwp/Parybys o.t.
Part 3: Mason County Public Health Review/Approval
Satisfactory ❑ Unsatisfactory IC
�slpnaWn wtEPNrml,e- �Hee_ IMapectelal _ gate d
This form may be scanned and available for public view on the Mason County Web Site.
aewsrn�azumu