HomeMy WebLinkAboutCOM2025-00101 - COM Sewer Adequacy - 9/15/2025 c,ory) a6a6 - 60 tc_ )
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415 N.eth Street.SIN e,Melton WA 98684
3W-427-0670 of 360 76448/,extension 400 i
Application for Determination of Sewer Adequacy
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Instructions: •
1.Complete Part t of application. Permit number may be added at later date.
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2.Take application,Site 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 elle plan for the project,showing all existing or proposed
sewer components and Units to relation to proposed development and property.
Part 1:Applicant I arcel informatl n
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• Applicant: Z rlk� ` \ Date: I l ��1�� j1 >
Mailing Address: -• 0-V-) 1' City,State,Zip: ,'.� S r \" `A 16 t
r 116 ,r�
Site Address: 1-, E L Phone: 'J 49 i
•) ) �. NO (.)t) (`' - Permit Number.
Number: i
Part 2: Sower System In ormation _
<� (_ t \ Sae Plan attached?
Name of Sewer System: I1 j�-'`
a Official use only: Sewer System Manager or Designated Employee is to complete.
0 New Corvucbon I have rovmw+d the apptxnnsa lnhvmsi,%l and haw nu rr+ucs with M.$tawr(:aunty Publ.r Health appwoving the co/resportdrnq
Mason County Pennve
In Existing Connection nun*(*viewed Ina amecante informatxXI,and have no iatt»a with Maven County I'vt.Fc Health approttng the
censspondrng Meson County Pefml
❑ I have rov»w+ed the applicants tnrcamahtw+and hay"rktiHmned met+Connection Is uwrrntty NOT avaeat.te to%tie property
❑ Please rckt the toCowa+p condieonta)on II*carrot IV son County Panmit tpplMatai) _
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prrMd Name of Staten Ltenaserl impala LG"arve Of Slam"►4tnagsw£wio ee Cent.
Part 3: Mason County Public Health Review)ApprovalcZiAliv.riy\lo(bOsA4,
10/27/25
® Satisfactory 0 Unsatisfactory
sigruture et Envvonmensai Health Speciaksl pate
'This form may be scanned and available for public view on the Meson County Web Site.
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