HomeMy WebLinkAboutBLD Small parcel storm water management (2) Public Health
Always working far a safer I- healthier Mason County
4 15 N 131h Series.BNp a.Shelton WA 98584
MO 427-9670 or 3606I7S41467,extension e00
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 sssodated information with Pie 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 Heam 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 t,
Applicant taUl}Cy12v✓.�uQIry3(.hTi'lG Dale: 3� �
Mailing Address, ' 1 t ..'1City,state,np Site Address. �- �ah hone.
Perm]Number y JGW permit Number
Part 2: Sewer System Information
Name of Sewer System Site Plan afUch vd7
Official use only: Sewer System Manager or Designated Employee/s to complete.
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Msem.LWnry Part,
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Part 3: Mason County Public Health Review/Approval
❑ Satisfactory ❑ Unsatisfactory
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This form may be scanned and available for public view on the Mason County Web Site.
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