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Home My WebLink AboutBLD2025-00895 - BLD Sewer Adequacy - 7/28/2025 7imiiimmemmir 60506 • 5 SpN COUNT), BLD2025-00895 Public -_ Health Always working for a safer ► healthier Mason County 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 I Parcel Information Applicant: Michael Dersham Date: 7/28/25 Mailing Address: 81 NE Ridge Pt Blvd#K-104 City, State,Zip: Belfair,WA 98528 Site Address: 20 E Island Place Allyn, WA 98524 Phone: (253) 495-8520 Parcel Number: 12220-54-00065 Permit Number: Part 2: Sewer System Information Name of Sewer System: North Bay Case Inlet ® 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. ® Please add the following condition(s)on the corresponding Mason County Permit:(optional) Must meet all Mason County design and construction standards, must pay all applicable fees including:connection fee with permit and inspection fee. Grinder pump required. Richard Dickinson � '-- -- 7/29/25 Printed Name of System Manager)Emp'.oyoe Signature of System Managed Employee Date Part 3: Mason County Public Health Review!Approvali'v°S 8/21/25 ® Satisfactory ❑ Unsatisfactory Signature of Environmental Health Spedallst Date This form may be scanned and available for public view on the Mason County Web Site. REVISED 1028/2015 MDERSHAM@GMAIL.COM