HomeMy WebLinkAboutBUILDING E - BLD Sewer Adequacy 13ulldlv� - ,44 unJ5
�50h cocr,'V-
Pub 1i
AWnYs working for a Sore nE3.'..dar"aSD'
415 N.Ban Stray,Bldg 9.Shehon WA 9858
M6 27-gi or 36b2T5445],extension 4DO
Application for Determination of Sewer Adequacy
Instructions:
1, Complete Part 1 of application. Pern-A 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 Pam it Center or Mason County Pubic 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 { V I Data
Mailing Add : ll il`�Ilmh/.ayt 'bit- t Ch State,zip: [j Oe- 3a
She Address: I VIE i�il to i5hone: .Z53-/n� ,^,lnr-19
Parcel Number. (a.�12Li- -QQ( J Permit Number. L+t2m 202.1 OOOaa
Part 2: Sewer System Information (,
Name of Sewer System: 21 A /.QL 1p.1 _ ❑ She Plan attachedri
official use only: Sewer System Manager or Designated Employee is to complete.
New Conn ma.ii new reabwe0 Me epamnb Inbmatlon and nave no issues wiM Mason County PUNc HeeM appmvipe Me mrtespondvry
Mason County Permtt
❑ Existing Comm ton: I lave reviexretl Me eppimne inbmatim and have no Imes win Mason Ownt,Public Hanh eprw+irg Me
mrmsp nding Mason county P—k
❑ Fave reviewed M,applimnl5 lnrwnolian end now dabm'me0 sewer w mn m Is son NOT iris.m tlY+pft
❑ Please add the blip s mnditr(s)m this rmespording Mason Count,Pemu[(optlonaq
LL.
me NSYstein si— B FmpM,H $Ta5^a tE SYs an MaaGwr Empbyee axle
Part 3: Mason County Public Health Review/Approval
❑ Satisfactory ❑ Unsatisfactory
signadm of Envimnmenbl HeeM specailsl Cate
This form may be scanned and available for public view on the Mason County Web Site.