HomeMy WebLinkAboutBLD2025-01141/SEWER ADEQUACY - BLD Water Adequacy - 10/28/2025 fe)
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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.
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Part 1:Applicant I Parcel Information
Applicant: Dawn cook Date: 10/20/25
Mailing Address: 21 e sherwood rd City,State,Zip: Allyn wa 98524
Site Address: 640 e Sherwood creek rd Allyn wa 98524 Phone: 3607319523
Parcel Number: 122301100020 Permit Number: B1d2025-01141
Part 2: Sewer System Information
Name of Sewer System: 1 _) n iSito 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 d the following condition(s)on the corresponding Mason County Permit:(optional)
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Signature of
Printed Name of System Manager/Employee 9n System Manager!Employee Date
Part 3: Mason County Public Health Review/Approval RA}AoliNio5 10/28/25
® Satisfactory ❑ Unsatisfactory
Signature of Environmental Health Specialist Date
This form may be scanned and available for public view on the Mason County Web Site.
REVISED 10/28/2015
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