HomeMy WebLinkAboutBLD Sewer Adequacy - 1/20/2021 tiosoN CO�•y4. RECEIVED
Public 47 Health JAN 2 2 T
Always working for a safer ► healthier Mason County MASON CO.UTILITIES
415 N.6th Street,Blip 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. development to the Sewer
2.Take application,Site plan,and any other associated information with the proposed
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
**Wet-components and lines in relation to proposed development and property.
Part 1:Applicant I Parcel Information
Applicant: J &J Development, LLC Date: 1/20/21
Mailing Address: P4 Box 623 City,State,Zip: Burley,WA 98322
Site Address: Block 60,Lot 1 Phone: 253-208-8136
Parcel Number: 12220-50-60001 Permit Number
Part 2: Sewer System Information
Name of Sewer System: ❑ Site Plan attached?
Official use only: Sewer System Manager or Designated Employee is to complete.
p9�t�ew Connect opm I have reviewed tie applicants information and have no issues with Marion County Public Health approv„p the corresponding
T7�� Mason Gouty Pent.
❑ Existing Camedlorc I have reviewed the eppricants hd'a matiu.r and have no issues with Mason County Pubic Health approving the
corresponding Motion County Permit
[� I have reviewed the applicants information and have determined sewer correction is cunanty NOT available b tie property.
Pter..„ add the following )on the corresponding Gourds Permit
pr{nlud Narno of tsysMrn Managed Employer
Moues*ot System Managed Employee Oat.
Part 3: Mason County Public Health Review/Approval
❑ Satisfactory ❑ Unsatisfactory Signatuaie of Environmental Health Spedafist Date
This form may be scanned and available for public view on the Mason County Web Site.
REVISED 1 Y2 2Ots