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Public Health
Always vmrking for a seep nea:.te:N!sor Ca_-,r,
415 N.Sin Sbeel,Bldg 8,Shelton WA 96584
350.427-9670 or 5 2754467,extension 100
Application for Determination of Sewer Adequacy
Instructions:
1.Complete Part 1 of application Perms 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 a0 existing or proposed
sewer components and lines in relation to proposed development and property.
Part 1:Applicant I Parcel Information
Applicant/`7j��','�pl, ��r)n5 +- ylk3.J >dQdAj mu4.#"� Date:
Mailing Addr s6k Ilryyj pjl,mh A^A br- 5�nt cr+y State,Lp: 0b 3q
Site Address: I I)E 4� to t*hona: .2. n _la'-19 -O(o 3C.P
Parcel Number.�AQ-A- 'O)3 Permit Number.. L.om Zo2-1 - 600 2- 1
Part 2:Sewer System Information
Name of Sewer System: T2fr'.l Ain . M u rBA'- ❑ She Plan attached?
OffiNal use only. Sewer System Manager or Designated Employee is to complete.
New Connection: I In w evie Vro ap lint=irmmatim and tare w issues a Mawr Cmr,Puaiic Heab wpeJny Va mnewmtling
Mawr Cw PemVL
❑ P rs Connection M1ave mieeeE th apprmn6lmomadon eM M1are no iseuswb Mvsm Couny Public Hmb gapmuinp be
mtespo ins Mawn County Pelt
❑ IMN%nrk-.ed"eppamms inmmation and nave d,W ,-d sawmnnec e a armb NOT evaNbbm Vis plop"..
❑ %asae Wd ON,lbA ,mnd".)on ft ee,,np dh,Mown Co.*PemVt(op6mao
PnYd N.n.msrawn MeuMEmgoyee siaam.msya.m Mwyu/bnpMee om
1 Part 3: Mason County Public Health Reviewi Approval
❑ Satisfactory ❑ Unsatisfactory
Signahm of EmAennwdN Haab Specialist Date
This form may be scanned and available for public view on the Mason County Web Sme.