HomeMy WebLinkAboutcom2021-00020 - COM CD Environmental Health Review 13ulld ivi C - 12, unto
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415 N.Bth Street,Bldg 8,Shekon WA 98684
360427-9670 or nD-275 67,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. Submd 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/Parcel Information
Applicant }- Date:
Mailing Add a: I I�AS !7tmhr,4n b� S �.t i s e,zp �L ,. �-�o e- 1 i111 �1�ri33'a
Site Address: I Y1E Tll q�blllt 'ttVA - shone:;Z6 �- 149 -OLOW
Parcel Number.�' '�2-8L -MX) Permit Number �m 202I 000�0
Part 2: Sewer System Information
Name of Sewer System: van u �� ❑ Site Plan attached?
Official use only. Sewer System Manager or Designated Employee is to rnmplete.
New Connection: hece reviawetl Ne aPM�® mfomution antl have m Issuev wM Msaon Lounry Pubic HeaXM1 eppmullq the crnRSpontllrp
Mason County PemM
❑ Exisli�g Lbnrrer9on: Mve rniewed Me eppk h 4Mrrmbdn antl hen no issues wf r Mason GouMy Pudic Hee1N ep'ro og the
m�Ponding Mason County PertnA.
❑ Mn mAeretl Ne appllcenrz Inlwnatlbn antl tun dabminetl sewarannecEm iz m�dy NOT availabk4 tivs ptogM1y.
E. Please add the Mom,mndmonlsj m Cre mrrespordng Mason Courn'Paco tt(Pptlwuq
Prv60f1emeuf SyaWn Mmeom/EmpYryee Myuave6SyMem Mangv/Emp6yee OM
Part 3: Mason County Public Health Review/Approval
❑ Satisfactory ❑ Unsatisfactory
signaan a Bnwrbna,enbl Hearn speoelrx Dam
This form may be scanned and available for public view on the Mason County Web She.
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