HomeMy WebLinkAboutHOMEOWNER INSTALL APPLICATION SWG2022-00547 - SWG Application - 4/3/2023 i
''f ' 1 '. 146(11 14"/ 71/0 AA,,t/al Ar2) .
N I I I 415 N 6TH STREET, SHELTON WA 98584
MASON COUNTY SHELTON:360-427-9670, EXT.400
I,; i' - 1COMMUNITY SERVICES BELFAIR: 360-275-4467,EXT.400
ELMA:360-482-5269,EXT.400
Building,Planning.Environmental Health,Community Health FAX:360-427-7798
HOMEOWNER OSS INSTALLATION REQUEST /•
Name of Applicant/Owner: K '"1 / Cil Qe/ af 05'1/RBI Date: Li/ 3l
Mailing Address of Applicant: l 910 5- S Sf
City: T-GCo rt/ct- State: (ma. Zip: cq.r4/o.-
Phone Number: ?-2,7 L— .2.37,6 P Email: /A/6a e Ia'r - /PIvP ham 4,,,,
12-digit Parcel Number: —5-2O0 i—7 '"--c 24'
Approved Septic Permit Number: SWG 2U 22 — 0 O SY 7 (see page 1 of design form)
Septic Design Expiration Date: /'
11 q1// -S (see page 2 of a e design form)
Septic Designer or Engineer: �-- �'A IUe.uff- (see page 1 of design form)
Designer/Engineer must stamp their approval for homeowner installation,
Owner Agreement: Uesii;ner/Bg er S -j ,p:
I am the primary owner of this non-shoreline residential property and P -k if1or a
this will be my primary residence. I have read and understand the .Air k, of S1s 9��1
attached "Mason County Homeowner OSS Installation Injoi oration". .iy. s J._� �'lIS
I agree to follow the Mason County procedure, standards, and ..,�� v,/.
applicable regulations during this installation with the understanding c Lr>oY wvITA -- 44
that failure to do so may render urn design/permit void or unusable. r LICEN' DE �__R 1le
Ln''''' 5 0510/ "",
of f. ; RG'„ 5',..,/- vt. ,.
Signature of Applicant/Owner 1,— 1___ ' "
___ .-_ __
HEALTH DEPARTMENT USE ONLY
Request Review: ) Approved ❑ Denied _
INSPECTION DATES:
Name of EH Speciilis �-�.�L- /
,, ,a�^ Pre-Install Meeting: > f 2 2
,//ti
Signature: l (�/ �'w v _ Date: el
D/F Depth Inspection:
)6
Comments: �e2 Final ins•action: � ��
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gd r V1.Xt D
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This form may be scanned and available for public view on the Mason County wlill e. A P R 06 2023
U - Updated 9/12/2017
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