HomeMy WebLinkAboutBLD2026-00167 - BLD Sewer Adequacy - 4/24/2026 BLD2026-00167
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Always viorking:for a safer healthier Mason County
415 N.6th Street,Bldg 8,Shelton WA 98584
360-427-9670'or360-275-4467,extension 400
Application for Determination of Sewer Adequacy
Instructions
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 devoloprnent tofthe Sewer
• System Manager or Designated Employee for approval
3. Submit cbmpleted application and information to Permit Center or Mason County Public Health for review.
NOTE:Vou must supply the System Manager with a site flan for the project,showing all existing or proposed
see ter components and,lines In relation to era osed development and property.
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Part 1:Applicant I Parcel Information
Applicant: Date: � �-
Mailing Address: �__ 1� City,State,Zip:_
Site Address: ,ll� G. �l Phone:
Parcel Number: Z a - -� � . Permit Number: flLu. t UUV
Part 2: Sewer System Information
Name of Sewer System: A `+v G Site Plan attached?
Official use only.- Sewer System Manager or Designated Employee is to complete.
New Connection: I have reviewed the appiidentsardormation and have no issues with Mason County Public Health approving the corresponding
Mason County Permit.
❑• Ex'isting Connection: I have reviewed the applicants information and have,no issues with Mason County Pubic Health approving the
corresponding Mason County Permlt.
O I have reviewed the applicants information and have determined sewer connection is currently NOT available to this property.
Q Please add thefolloydng•condition( on the eerie spondingiiason ounty Permit:{optional))
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Printed Name of System Manager/Employee Signature of System f tanagerlEmployee. Pate
Part 3: Mason County Public Health Review/Approval 4/24/26
Satisfactory ❑ 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 1W2Sf20t5,