HomeMy WebLinkAboutBLD Sewer Adequacy - 9/11/2020 (2) worm
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ENVIRONMENTAL
HEALTH
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Always working for a saferhealtfiier Mason County 615 W. Alder Street
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/Parcel Information
Applicant: J &J Development, LLC Date: 8/26/2020
Mailing Address: PO Box 623 City,State,Zip: Burley, WA 98322
Site Address: Block 60, Lot 10 Phone: 253-208-81363- Q
Parcel Number: 12220-50-60010 Permit Number.34 ci 2O -0 �U 1
Part 2:Sewer System Information
Name of Sewer System: 1 -1 \ 0 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 Public Health approving the corresponding
Mason County Permit
❑ Existing Connection: I have reviewed the applicants Information and have no issues with Mason County Public Health approving the
corresponding Mason County Permit
❑ I have reviewed the applicants information and have determined sewer connection is currently NOT available to this property
leaseAdd the following condition(s)on the corresponding Mason County Permit(optional)
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Printed Name of System Managorf Employee Signature of System Manager/Employoo Date +
i.
\Part . Mason County Public Health Review/Approval �� }D(2� `��
( Satisfactory ❑ Unsatisfactory
Signature of gnvitonmerttaI Health Specialist Da
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This form may be scanned and available for public view on the Mason County Web Site.
REVISED 10/282015
Printed from iviason County DMS
Printed from Mason County DMS _