HomeMy WebLinkAboutBLD Sewer Adequacy - 11/14/2024 NSON COVIV
Public Health
Always working for a safer healthier Mason Counry
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415 N.6th Street,Bldg 8,Shelton WA 98584 Maepn Cp4 y 1014
360-427-9670 or 360-275-4467,extension 400 e(y Utilities CO.
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Application for Determination of Sewer Adequacy
Instructions:
1. Complete Part 1 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 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 I Parcel Information
Applicant: Marcy Goldstone Date: 14 Nov 2024
Mailing Address: 4625 Forest drew Lane SE City, State, Zip: Port Orchard, WA 98366
Site Address: 50 E Virgil Drive Phone: 206-537-6799
Parcel Number: 122185200016 Permit Number:
Part 2: Sewer System Information
Name of Sewer System: Mason County ® Site Plan attached?
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only: Sewer System Manager or Designated Employee is to complete.
onneclion: I have reviewed the applicants informalion and have no Issues with Mason County Public Heellh approving the corresponding
County Permit,g Connection: I have reviewed the applicants information and have no Slaves with Mason County Public Health approving the
ponding Mason County Permit.revkwed the applicants Information and have determined sewer connection is currently NOT available to this property.
add the folbwing canditlon(s)on the corresponding Mason County Permit:iopgonLc x�H-/ y.eP.dsomedsyelem Man'.0Empbyee bpneWre daysbm Manperl Fmporee Dale
Par.1tt 3�: Mason County Public Health Review/Approval
�ILLSatisfactory ❑ unsatisfactory
�r"" Signature I`vlrental Heellh statist Dale —
/ This form may be scanned and available for public view on the Mason County Web fine.
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