HomeMy WebLinkAboutBLD2025-00309 - BLD Sewer Adequacy - 4/21/2025 'ON cotjtv .�..........
Public• Health AUG 0 6 2024
Always vroi king for a safer healthier Mason Calmly
415 N,(th Strnnt,Bldg 8,Shelton WAOS504 Michele Remmen x 56611TW
360.427.0070 or:1110.275.4407,extension 400
Application for Determination of Sower Adequacy
instructions:
1.Complete Part I of application. Po•tnit number may be added at later date.
2 TaIo application,Site plan,and any other associated informalioit with ih:r proposed development to the Sower
System Manager or Designated Employee for approval,
3-Submit completed appiication and information to Permit Canter or Mason County Public I iea!th 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!Parcei Information �/
Appli ant: f-A'O4',S 4�' , LGL Date: 1r�s ' T Mating Address: /1 —�—7-4 City,State,Zip: L•e--. 7 c�
s7ss
Site Address: a/ "7A.Q/e ,454 Phone: Z4e0, Z4e)
Parcel Number. r -4'40 Z../ Permit Number: -E.)1 2.6r2c - -)09
Part 2: Sewer System Information
Name of Sewer System: fi <.. �. Site Plan attached?
Official use only: Sewer System Manager or Designated Employee Is to complete.
Eirre4:f Coenmiion: I have rev,ewcd t'+a applicants talormation and have no Issuer w:t1r Mason County Purple Health approving the correspond o
Mason County Perme.
❑ Eristing Catnedlon: I have reviovrnd the epp5cants Informetton and have no issues MI,Mason County Punic Health approving the
cotresporxtinn Mason County r'eun.t
❑ I have revowed the app l,cante Informoton and have detormtnoe cower oonneceon N currently NOT whole to the property.
Ptearo add the mowing cond,bon(s)en the corrospwnding Mason County Permit:(ap6amr)
/ G'cL1-S1 "i2r14- ieS mkt as r, sx per•/I
/ry 1 /1/ /0'IYi1K- -4-• t/ 1��-�/;.. l ,f'✓a�.ite.-e
Ported from of Sodom WNW', Lryrarwe el 6)stem Manager,Frpovaa Dare
Part 3: Mason County Public Health Review!Approval r 'ff���
Satisfactory ❑ Unsatisfactory J C•
Sip.mtwo of Envhenm I leatth Spedatis! Date
This form may be scanned and available for public view on the Mason County Web Site.
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