HomeMy WebLinkAboutBLD Sewer Adequacy �osoN COUN?aA
Public Health
Always working for a safer healthier Mason County
415 N.6m slreet Bldg a.Brunch WA 985"
MG-,127-9670 or 360 275M67,eatension 400
Application for Determination of Sewer Adequacy
Instructions:
1.Complete Pan 1 of application. Permit number may be added at later date.
2.Take application,Sao plan,and any other associated informanon with the proposed development to the Sewer
System Manager or Designated Employee for approval.
3.Submit completed application and Information to Permit Center or Meson County Public Hoehn for review.
NOTE:you moat 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 I Parcel Information
Applicant: i2ith" Vlubcll. RI.a Lanrt Date: 3,�/G •2nZ t'
Mailing Address: '' 4290 E. Sa. City Stale,Zip: 134, sp-. WA dl S�.i28
snenaare6s: 4261 E SA- 3o2f r. WiPhone: Zc1. - 331- oo9 'b
Parcel Number: , Y'LZ I - 5 N - 90 A71— Permit Number.
Part 2: Sewer System Information
�Ay+h 40 �Ny�y p snePlananacned?
Name of Sewer System:
Ofgclaluseonly: Sewer System Manager,or Designated Employee is to complete.
Naw Connedron. 1 save reviexM the appl,Canta Inbtmetion eM have m esuee vnN Mason County Pudic ,sure alon"na Ina ourlawoMi�q
fill
Mason County PmmB
❑ Exisl�n9 Cennwron t nave reviewed ale apphrane alomleaon and haw na nnaeaasxh Mawr County Pubic Nemlh ap--n.the
oone6po vr, Mount Count'Parfait
❑ Ihave rav,awed the app cants inlorma0on and Mve downtrad saver psnnedbnM wmndy NOT avalleble to this P"T
❑ Paaw add Na Who-MMdNanUI N Na OJrteapoMhp Mdwn County P.owt(aarronae /
PMIM Nema M waMm M anadall E,rybyae
6pnslNltlByaMm Man.,s..- seta
Part 3:Mason County Public Health Review/Approval ,� �(
Satisfactory ❑ Unsatisfactory glgnaturedEml meMalNOIal BpedallD Data
This form maybe scanned and available for public view on the Mason County Web Site. eeeaw I.."
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