HomeMy WebLinkAboutBLD2024-01350 - BLD Sewer Adequacy - 11/12/2024 416 N.(ITH STREET,BLDO 8,SHELTON 1111114
MASON COUNTY SHELTON:084427-WRO.EXi 400
COMMUNITY SERVICES aEELMA:NO.462J46],UT.400
ELMq:0B0 FAX 364) UT.408
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FAX ae0 42ZA0a
Application for Determination of Sewer Adequacy
Instructions:
t.Complain Pan t of appllcallon. Penult 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 ells 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: "T UHe-0 itch r AN Dab. W 1 Z— Z y
Mailing Address: 141681 ' by v 3 CIIy,Ststa.zli: Auvul ova 991S.1k.l
Site Address: Phone: �L�a /I
Parcel Number. l :):)Q 0 -&0 -39004-1 Perms Number. 61.09COL �3
Part 2: Sewer System Information
Name of Sswer System: ❑ Site Plan attached?
OMcleluseonly: SewerSyslem Manager w Designated Employee is to complete.
flex CMnsylM: 1 how mleuell an algYeenls Mkrmallgl an0 Mve no bwee wily Meem Cpunry Pu011c HaNN epploNna IM1e wnnpw0ke
I Mewn CWnly PelMl.
❑ Eeldno Ch,mechcht, I hove revlewee the ePPrcents lnlhmeocn a,d hew no lseuesweh Mown County PuNlc HeolNappmWp she
mmree,ollne Meson Oaunly P.,"t,
❑ I Mw nvkweJ ale oppreanle lnlwmeLbn and M1eve thowas1eU aMvr wnneeton he wo nfy,NOT evNleble W Nle whether.
� Telenet we in.baovloo wnawhMtl m the cNleephMbp Mown county Permit toafi nwq
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Pnlae Ntmsaearu.m Mwxprl Empbwa spweagrNe/M.'.e.uEmevr.e or
Part 3: Mason County Public Health Review/Approval //) ,1 // .i
Satisfactory ❑ Unsatisfactory `. 2= 1 1 r �V Ll
SMnswe d EnKhmmnlel Heap 1/� Dale
This form maybe scanned and available for public view on the Mason County Web Site.
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/ WATER LINE
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OVERHANG �, 0, �
SEWER LINE
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I
-SITE PLAN
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J HN N MAN
19600 EAST H y S
A LYN, WA 90524-9T41
PAW,M HAM
12220-50-54004
THIS SITE PLAN 15 DRAWN BASED ON
DATA SUPPLIED BY CLIENT AND WITHOUT
BENEFIT OF SURVEY OR TOPObRAPHY
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