HomeMy WebLinkAboutBLD Sewer Adequacy - 1/5/2021 APPLICATION FOR
SEWER UTILITY SERVICE
MASON COUNTY
UTILITIES & WASTE MANAGEMENT
100 W PUBLIC WORKS DRIVE- P 0 BOX 578
SHELTON, WASHINGTON 98584 (360) 427-9670 ext 207, 283, 566
DATE 1 \51 2 )21
PARCEL# \221D ' 131°(:)1
SITE ADDRESS S2 � . ?7(O
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OWNER NAME R Kvx\r\,`
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BILLING ADDRESS C�O�
WORif\ VI Or act
ANTICIPATED DATE FOR SERVICE TO BEGIN
I agree to the terms and conditions of the Mason County Codes and/or
Resolutions. (Copy available upon request.)
SIGNATURE cjs
A COPY OF CONSTRUCTION SITE PLAN MUST ACCOMPANY THIS
APPLICATION.
FOR.OFFICE USE: 1
1 •k Date 1 �k Receipt}#�/ Q 1 5?
Connect Fee, l i ��
Grinder Pump Date Receipt 4
Vacant Lot Fee Effective
Monthly Sewer Rate Effective
Building Permit #ecL)``^JiM Date Issued Date Final
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