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HomeMy WebLinkAboutBLD Sewer Adequacy - 6/26/2025 VI itteL i(1,4 (ej LIIDD C41 WI .0,2501N1 cowl Publtc-N40Health 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: Complete Part 1 a application. Permit number may be added attlater date 2.:Tat<e application,,Site plan,"and any other associated information with the proposed development to the Sewer System Manager or Designated Employee'for approval. 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: f,te-Y'►.G t4 �C�W t,v14+ Date: (Mailing Address: (Q /l$ C 1/i* City,State,Zip: a,A4six iiid- qtr/é ,l Site Address:72.4o a Writ e4.• �� Phone: A.1 2,33if/ Parcel Number: 1 2,sZ 2 q I 3100410, Permit Number: Part 2 Sewer System Information Name of Sewer System: o rtirN B4rY 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) fJ /y �r /4/ 1 ,^;•!/r3rt�af�/d%/.' 1 ° 'PA, �S 5 i/lr r'PAG}"- f3f c, ,,..764+ ° � f"`e i a�l ,,rte..} 1ff + �'y' ,(may/ it Y ` .. "7 /�...'GdZ� j/,�,✓.� $ JJ `'''''' ilf iii,L+4. /. 4,<7+'1'f <. L a • r,( f t.. 4�J `� .I fit...�,'"}✓"^." LH".._� [�- j .,�t✓+"exlC`YrGdrY",�if i. /-w'` CL.'d /,r°yl Printed Name of System Manager/Employee j Signature of System Manager/Employee Date Part 3:Mason County Public Health Review/Approval 3/4/26 © Satisfactory O Unsatisfactory Signature of Environmental Health Specialist Date * condition added This form may be scanned and available for public view on the Mason County Web Site. REVISED 10/2&2016