HomeMy WebLinkAboutBLD Sewer Adequacy - 11/12/2024 �?,SON C011,V
Public' Health
Always working for a!.!for healthler Hawn County
415 N.6m Small,Bldg 8,Shelton WA 985M
360427-9670 or 360-275 4467,extension 400
Application for Determination of Sewer Adequacy
Inebuclione:
1.Complete Part t of application. Permit 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 informalion to Permit Center or Mason County Public Health for review.
NOTE:you must supply the System Manager with a$I%plan for the project,showing all existing or proposed
sewer compensate and lino In nleaon to proposed development and property.
Part 1:Applicant/Parcel Information
Applicant:Md b r� p(y 6y- Date: 1 4
Madng Address:%37;JGj r—hito nU-N City,Stab,2ip:-�YOl'y1 j k* WA INyil a.
Sae Address: TgD E: 61111 kI/KiN s,-f�>d l l w _Phone: t,41 d) 731- Agin
Parcel Number'. 1 a.A�x(]". -- •—�Parmit Number: -L�I(I 2,A `Y - 01341
Part 2: Sewer System Information
Name of Sewer System: )A Site Plan attached?
Official use only: Sawer System Manager or Designated Employee Is m crompleb.
�j New Connwim-. IM1aw,wbwea Ne eppvnh lnlmmMun ant Nw no bwe.wMN+wnCwny Pudic NaYlM1 approHnp Uro wrceponaba
r W.County Peneu.
❑ Evstlne C^metlicn. Ihew,aviewea Ne applunleinfamYbn ak hew no bwea wAh intent Cwny PudK NeaIM aPPraving lip
Ur ."xin,Ms.Cony Petmk.
D I have reviewed Her., eanb inInrmidim and h.Mbnnlinev.MCom anal b annoy NOT winds to Mis awards
m Reem add nor evac eeia wnelJ nbl.vie wmgwndlnB Msmn County PamM foptlang
/ -F . er
Sal a,./ ! re y,w+e
Pnm.axmpaswMm xu»sens�p» sgnYw.as»wn Ma,,.enr Pmay.. o.p
Pa....rtGGt 3:Mason County Public Health Reviewl Approval ^ .^ - ^� �
Satisfactory ❑ Unsatisfactory a nM.e' "NJ
sgnemp a-V'�,.�s eP.ryx l/ f oea
This form may be scanned and available for public view on the Mason County Web Site.-}\
WELL 50-� 100"
-�- WATER LINE
SEWER LINE
GRINDER PUMP
�e eHo MTH
DIRVEKA)� U)
: :.. 51 TE PLAN
1" = 20'-0"
I.
ONER
I
MCOORMIOK CONSTRUOTION LLO
3125 OHIOO AAY NW
BREMERTON,PIP.93312-1321
PARCEL HPOEM
12220-50-99003
THIS SITE PLAN 15 DRAWN BASED ON
DATA SUPPLIED BY CLIENT AND WITHOUT
BENEFIT OF SURVEY OR TOPOGRAPHY