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HomeMy WebLinkAboutBLD2026-00487 - BLD Sewer Adequacy - 9/1/2026 , oN CO(rli,r I_)) q y � I Health 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: 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: MILLION, MARTY D & RENAE LYNN Date: t6 �i l �i Mailing Address: PO BOX 241 City, State, Zip: Allyn WA 98524 Site Address: 240 E Sullivan St. Allyn WA 98524 Phone: ( .-\ I - L. lei Parcel Number: 12220-50-58009 Permit Number: Part 2: Sewer System Information Name of Sewer System: NBCI ® 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. El 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 co dition(s)on the corresponding Mason County Permit: optional . €x (wed � ltuvri sewwe r' Richard Dickinson 8/11126 Printed Name or System Manager/Employee Signature o€System Manager/Employee Date Part 3: Mason County Public Health Review/Approval � 5 9/1/2026 XJ Satisfactory ❑ Unsatisfactory Signature of Environmental Health Specialist Date Fees must be paid prior to issuance This form may be scanned and available for public view on the Mason County Web Site. REVISED 10!2512015