HomeMy WebLinkAboutBLD2025-00151 - BLD Sewer Adequacy - 3/19/2025 10MU
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Public Health
Always working for a safer healthier Mason County
415 N.6th Street,Bldg 8,Shelton WA 98584
360-427-9670 or 360-275-4467,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, 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 )W"155 EI,)L`(GE 465P✓,LLG Date: 12-is - 2014
Melling Address: Zbl z,y1' pll.tS%o D sv! city, state,zip: VDA14601 V `I80-go
Site Address: II r 9Va6l96N dFt- 8) Phone:1z bi; 4 - �;ym
Parcel Number: 2ZIZl-�Z'S- 00030 Permit Number: P311�`all ,-ri-D� r
Part 2: Sewer System Information — /
Name of Sewer System: .V4 S J"Lr wV0 D ak Site Plan attached?
Official use only., Sewer System Manager or Designated Employee Is to complete.
New Connection: I have reviewed the applicants information and have no issues with Mason County Pudic Health approving the corresponding
Meson County Permit.
Existing Connection: I have revlewed the applicants Information end have no Issues vnth Mason County Public Health approving the
corresponding Mason County Permit.
❑ I have reviewed the applicants Information and have delerrel m l sewer connection Is currently NOT available to this progeny.
❑ Mass add the folbwtng condtgon(s)on Has coreapondi g Masan County Permit (optional)
Printed Name of System Managed Employee Slgnawrs o19yaYm wa.W Empioys Date
Pa : Mason County Public Health Review/Approval_ o nM �f IG�IZ�
Satisfactory ❑ unsatisfactory &2a8e�t
signature of Envtrdnmntal Health Specialist Date
This form may be scanned and available for public view on the Mason County Web Site.
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