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Home My WebLink AboutCOM2025-00090 - COM Sewer Adequacy - 12/11/2025 -lb Doi 7I) 50N COu R C1 _,> 0' n'1 10 QEC 11 2025 Public Health n, , , Michele D, ruleAlways working for a safer ► healthier Mason County 415 N.61h 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: JUSTIN LEE &ANGELA CHOI Date: \i1 i\ 2 Mailing Address: 190 NE BECK RD City, State,Zip: BELFAIR WA 98528 Site Address: 23781 NE STATE ROUTE 3 BELFAIR Phone: 253-882-5606 Parcel Number: 12329-41-90111 Permit Number: COM2025-00090 Part 2: Sewer System Information Name of Sewer System: BELFAIR SEWER 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. t 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. 2 Please add the following condition(s)on the corresponding Mason ounty Permit:(optional) / �as,, aG..s,..., yob.. l./1.1,. A .ret,firm.; 4E" / er�✓rr/d �`'fe "�/� , 444071.2M. die,f 4a i.2 ....r.,.,. , ....L -2 Richard Dickinson J /2,1S zvZZs` Printed Name of System Manager)Employee Signature or System Manager/Employee Date Part 3: Mason County Public Health Review/Approval RA/NylplempS( 4-. 12/16/25 El Satisfactory [1] Unsatisfactory Signature of Environmental Health Specialist Date *conditions added This form may be scanned and available for public view on the Mason County Web Site. REVISED 1028/2015