HomeMy WebLinkAboutBLD Sewer Adequacy - 11/4/2024 ENVIRONMENTAL
HEALTH - CEfVED
4In5ON C0JJ'V Nov - 4 2024
Public Health Aider Street
Always working for a safer healthier Mason County
415 N.eh S1reM.Bldg a,Shelton WA 98584
%0 427-W70 or 0 275.4167,evlension 400
Application for Determination of Sewer Adequacy
Instructions:
1.Complete Pad i of application. Penot number may be added at later dale.
2.Take application.Site plan,and any other associated Information with the proposed development to the Sewer
System Manager or Designated Employee for approval.
d.Submit completed application and information to Permit Center of 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 I Parcel Information
Applicant:LAKE,PATTY Dab: 10I282024
Mailing Address: PO BO 22121 city,Stale,Zip: BELFAIR WA 98528
Site Adda ss6l E LOOKOUT CT GRAPEMEW WA 98546 phone: 960-801-0570
Parcel Number: 22127-52-00056 Permit Number:
Part 2: Sewer System Information
Name of Sewer System'RUSTLEWOOD [ Site Plan attached?
OElcieluseonly: Sewer System Managercr Designated Employee is W complete.
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This form may be scanned and available for public view on the Mason County Web Site.
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