HomeMy WebLinkAboutBUILDING F - COM Sewer Adequacy 13 ) IV F - 2� unit
,tN 7,50N C00V
Public Health
Always working fDr 3 We S ne3:]12(f•:a5(N.iD_Li;
415 N.6til Street,Bldg 8,Shehon WA aa564
360427-96/0 or 3(30.27S 7.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, She plan,and any other associated informabon 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 Heahh 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
Appel-ntdI4=nfr,4on5i-4- VIUA) A04AAMLu S Date:
Mairmg Add4s: 115D5 tm .Mn 'Dy_ 5 l chy State,Zp: a
Site Address: 91 AE AR144.4blAtPhone:_Z SS— 0 U49 '01a5LP
Parcel Number Perm Number 0-Ory12621 - d00a3
Part 2: Sewer System Information l
Name of Sawer System: rj.I r l A V5JAL .l ❑ Site Plan attached?
Official use only: Sewer System Manager or Designated Employee is to complete.
El New Conn-ton, I bars reviaved the apptoana intonation and have no csuss w Ws Coen Pudic Hadlb apptoNnp aw wmaponong
Mazur Cwny Pamt
❑ Bd M Ceraee6on: I tare�tla applkaMs intimation and nos no beues w Mason Coin'Public Hoohn apparing the
omegondin g Mason Goarty Permit
❑ Irave mviewed tlaa opronsInlonniaEcn antlM1m debtnJrnE aexvr mnnaSonbom NOT avaaede b N4 pvpary.
Please edo the b.11 tondtottta)on the mnespo,M.Coady Perri[(ppWal/
PnbE Nvmaf sYmen MaaWtl FsiMayu SW4aa N5)'oxn Maspn EnWHr Dee
Part 3: Mason County Public Health Review/Approval
❑ Satisfactory ❑ Unsatisfactory
vgne or EmmonmeMal He spadatist Date
This form may be scanned and available for public view on the Mason County Web She.
ansro naaam:s