HomeMy WebLinkAboutBLD2025-00112 - BLD Sewer Adequacy - 1/29/2025 e)t'pa09"5 - 0ol/ 'L
RECEIVED ENVIRONMENTAL
1AN 29 2025 HEALTH
615 W. Alder Street
415 N.eTH 5mEET,eLOG B.SHELTON YW W584
MASON COUNTY SHELTON:aWiP-BBIa,E%T.YW
COMMUNITY SERVICES 6EEFMa a6a-PSYe],E(L 400
ELM43a0iB23a58,EYL IN 40a
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Application for Determination of Sewer Adequacy
Instructions:
1 Complete Pad 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 compieled.application and intonation to Permit Center or Mason County Public Health for review.
NOTE:You must supply.the System Manager with a she plan for the project,slowing all existing or proposed
sewer components and lines in relation to.proposed development and property.
Part 1:ApplicantE_Parcel Information l �^,
Applicant l aflY/6S iif6-�'C Date:: q• 110 -114"
MaigngAddress: zl za Au Xya City,state,zip: 1,11 t n R7�0
Site Address: Z+c n Jl L-el Phone: 'ri o "7s o1� /
Parcel Number I'L 7, — �h-�011 Permit Number. AI
Part 2: Sewer System Information 11 /
Name of Sewer System: k Y' l V Slte Plan atfad*d?
Official use only: Sewer System Manager OtDeslgnared Employee Ism complete.
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Meson county
Permit
❑ EMetlne Connepion: Ihew reviw.eElM aPPW':na inmmratlan ud heye rw hsueatMa,Masu,CauntyPWllc HeeM appmnrq cite
omresporNha Mason County P.R.
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Part 3: Mason County Public HeaUh Review/Approval ,T - ,__ „tCvq
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This form may be scanned and available for public view on the lMason`County Web Site.,ILYnP-
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