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415 N.6M Steel,BWg 0,Shah.VA 90504
W(i.427-9670 or 360-2754467,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 wfth the proposed development W the Sewer
System Manager or Designated!Employee for approval.
3.Submit completed application and information to Pemlit 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 t:Applicant J Parcel Information
Applicant r.t' V Ik3.l) AodlAA mLN,�S Dare: ' - 1_
Mailing Add s:I���jl7 l' /L•uyt �C_ 5 znl chY�m.Zip: &"—'o e. a
Side Address: I VAE hl In tThone: sZ 53' U149 —OLOW
Parcel Number Ia�2B- . -otxa3 Permit Number. Corn 202-1 - OOW 19
Part 2: Sewer System Information
Name of Sewer System: r/.I u/1r M Ott rPlrl ❑ Slfe Plan attached?
Official use only: Sewer System Manager or Designated Employee is to complete.
El Nee Concoction I he.re waad Me appilaNs Itdonrabno and have-issues aXh Meson County PUNic Head,apgoW,q Me mmanxadinn
Meson Cowry Pama
❑ E,daM,coveGon: 1 have nen.Me appl.n%r fwmatien and hen no ones aih Mason Cowry Public Naas,apladvkp Me
nine nandin0 Masan Cduiry P.L
❑ 1eave reviewed Me¢pear Inocumon nd Nw deamired. ndad.iz amMly NOT m 1I Mbp ;odry,
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Part 3: Mason County Public Health Review/Approval
❑ Satisfactory ❑ Unsatisfactory
Sveouni of E nxvrenlal Heath Spe®let oak
This form may be scanned and available for public view on the Mason County Web Site.
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