HomeMy WebLinkAboutRECREATION BUILDING - COM Sewer Adequacy - 8/10/2021 1�' ul lCf I✓1 - ��c_.V'ew-�r�,,��, 1�'l d
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415 N.ath Street Bldg 8,Shahan WA W584
350-42]-95]0 ar 360.27S 7,eNenswn 400
Application for Determination of Sewer Adequacy
Instructions:
1. Complete Pan 1 of application. Pemhil 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 tc 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 Addr s: IIS�S mm aaAn b S �rsl ciy state,np: ul.l30¢. a
site Address: isl IlE i�i 1 Plhone: ea53-/n� ,^,LON9 -Ola'SLp
Parcel Number .8' -0=)5 Permit Number. tom 202-1 - 002-
Part 2:Sewer System Information L
Name of Sewer System: T 2a l u lA L' r hP ❑ Site Plan atached?
Official use only. Sewer System Manager or Designated Employee is to complete.
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Part 3: Mason County Public Health Review/Approval
❑ Satisfactory ❑ Unsatisfactory
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This form may be scanned and available for public view on the Mason County Web Site.
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