HomeMy WebLinkAboutBLD Sewer Adequacy - 11/20/2025 NOV 2 0 2025ub
° ; Health. Michele Nemuieu x 566 UTW
Aiways working for a safer hr•a tlaer Ma:.on 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/Parcel Information
Applicant: kyV-%-hrt,t-n `‘ TGhn -p)Gyf'es Date: ( l /i q I Z.CD -i.ZC`
Mailing Address: lot-1 N E 01,A. E ' - i,r R vvy .City,State,Zip: Bek ,5 c (0el
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(Site Address: (041 �e -1 UC'1�tG�r (� ' tom'Phone: 31,c0 P)01--031
Parcel Number: t2`3 20 14-3`\C)On b Permit Number:
Part 2: Sewer System Information `` 1 `/oLt.. ��v� V s 1 V
Name of Sewer System:_ L s'Nea� SVtar^c� �J( ' i, 'rG ❑ 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 Informafon and have determined sewer connection Is currently NOT available to this property.
® Please add the following condltion(s)on the corresponding Masonso County
yPPermit:(optional) //_ //' ,o
„4/..,,<-/:-.):)„,./„.. .4,
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Printed Name of System Manager/Employee Signature of System Manager/Employee Date
Part 3: Mason County Public Health Review/Approval j 0
xf Satisfactory ❑ Unsatisfactory t
S ' •re or
/ ronmontalHealth P ecialist Date
This form may be scanned and available for public view on the Mason County Web Site.
REVISED 10R8/2015
1