Loading...
HomeMy WebLinkAboutBLD Sewer Adequacy - 4/24/2025 4 r,soN CO tilt Public 'y''fl • Always working for a safer 4. healthier Mason Courtly 415 N.6th Street,Bldg 8,Shelton WA90504 APR 2 4 2025 360-427-9670 or 360-275-4467,extension 400 chole i cnunen x 566 UTW Application for Determination of Sewer!-ldequalyMk it Instructions: 1. Complete Part 1 of application. Permit number may be added at later date. 2.Take application,Silo plan,and arty 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 sower components and lines in relation to proposed development and property. Part 1:Applicant!Parcel\ l Information 1 Applicant: t1A QM V�.\ 0,(c G (b,op •WL Date: `I\ 1 .77 Mailing Address: It p 1,k)PJ�. \/ City,State,Zip: .SV\"\—y-bn ,if\ °t ?`JrK'H Site Address: 50 ,(yo\SU'kk- C-j-J C-V(IPMCI,J Phone: C.(9 V) s x1(} Parcel Number: _ 5 2 -. 000`o(J Permit Number: i�i C1 2, 0.6 - r r`7r]2 Part 2: Sewer System Information Name of Sewer System: R'J 1-w w l Site Plan attached? Official use only: Sevier System Manager or Designates!Employee Is to complete. New Connection: I havo reviewed the applicants information and havo 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 PormiL ❑ I have reviewed he oppiicants Information and have determined sewer connection Is currently NOT available to this property. Please odd the fort sing corttlllion(s)err the corrosponding,Mason ' only Permit:(optional r. GG2 C. .-/l r • '• Printed NOlnO of System 15;aged[mptoyoo $ipnatwo of Sy51om Wenger;Employee Data Part 3: Mason County Public Health Review/Approvals_41..f.ri)(49S(u4., 6/1 1/2025 (X� Satisfactory ❑ Unsatisfactory Signature of Environmental Health Specialist Date * condition added This form may be scanned and available for public view on the Mason County Web Site. ftEv1SED rease015