HomeMy WebLinkAboutBLD Sewer Adequacy - 3/11/2025 �ooN CopNr
Public Health
Always world for a safer healthier Mason County
415 N.BM Street Bldg 8,Shelton WA 98584
W0427-9670 or 380-2754487,general.4r10
Application for Determination of Sewer Adequacy
Instructions:
1.Complete Part 1 of application. Permit 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 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:i.maSa]yui('1Gl C(�R61�.1CdJS C1®� Date: Q},p\J
Mailing Address: City,State,Zip: 51,3El Isli
Site Address: 725LN l7K5T 9on"& 1atl4_m LV'?,O Phone: 50MO.4!;r-
Passel Number:A Its Permit Number:
Part 2: Sewer System Information
Name of Sewer System: Q%Ty CC: 4.l,�GJ LW 1A Site Plan attached?
Olflcial use only: Sewer System Manager or Designated Employee Is to complete.
Q New connecben: I have revewed the applicants informatlw and haw no issues whin Mason County Public Health approving the corresponding
``''Mason county Permit.
xMing Connection: I here reviewed the applicant Irdnrmetlon and haw no issues aiN Mason County Public Heats approving the
errssponding Mason County Pend.
❑ 1 have reviewed the applicants information and haw determined sewer connection Is wmnay NOT available to this property,
❑ Please add the following mndiaonfsl on the conaawnding Mason County Pe rat noplianarl
JG�J j
PNaeCNameIXSyaWrm Manayn/EmpYrye¢ mpn Nsyebm Manaael EmyYgee We
Part 3: Mason County Public Health Review/Approval _ ^�rn r� L
Satisfactory ❑ Unsatisfactory M V1' 1 yI L
11 Signature of Environmental Halifth specialist oat
This form may be scanned and available for public view on the Mason County Web Site.
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