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HomeMy WebLinkAboutBLD Sewer Adequacy - 1/22/2025 �ooN Couv PublicHealth Always working for a safer healthier Mason County 415 N.am Skeet,Bldg B.Shoulder WA9i WO-427-9670 or 360-275 4467,extension 400 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: Phi Vuong Date: 122/2025 Mailing Address: 10 NE Air Castle Lane City,State,Zip: Belfair,WA 98528 Site Address: 23293 NE State Route 3 Phone: 360-223-7641 Parcel Number. 12332-50-00921 Permit Number: COM2025-00004 Part 2: Sewer System Information Name of Sewer System: Belfair Sewer ® Site Plan attached? Official use only: Sewer System Manager or Designated Employee Is to complete. New connection: 1 have reviewed the apNNants Mfolmalbn aM have no Issues wllh Mason Ccunty Public Wolin approving the corresponding Mason County Permit. Jill Existing Connection I have reviewed Pe eppltrants iniwmalion and have no Issues WHO Mason County Pulak Heats aplxoviv Me .hresponding Meson County Permit. ❑ 1 have reviewed Ine v,,wana Information and have determined!sewer Connection is a,renlly NOT available Ie Ihia propeM ❑ Please add the follovling moothion(s)on the mrmsporMMg Masan County Permit(ophora9 / aC IL lY Ms YLi P,MadNmad SYdam Man,.Empbyae / Iwo a Sy..Menagul EnxoI seta Part 3: Mason County Public Health Review/Approval Watisfactory ❑ Unsatisfactory spnawre olEmim nm HaMlh Specialist Data This form may be scanned and available for public view on the Mason County Web Site. oPutwo unaaau A- p C- £ D-D•J: guXWnp glerderd lmPrd\'emsnle • q EXHIBIT A r- THE PREMISES -TU 111�71dly gRcK g 14 P�2. . . WAW;Aict xeneo o I �' 1 o'x Cq 16 J ... ao 'y 3LtITE B2 � 6x rr / FfanT Pkue In1eJ 9125 landlord T"t Pegs 13 o121