HomeMy WebLinkAboutSWG2021-00492 HOMEOWNER INSTALL - SWG Application - 8/8/2024 MASON COUNTY 415 N 6TM STREET,SHELTON WA 98584
COMMUNITY SERVICES 6ELFAIR:360-27554967,EXT.400
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FAX:3W-427-7798
HOMEOWNER OSS INSTALLATION REQUEST
Name of Appilcant/Owner: LCr t S� �,-...; �1�(- Date: _ gSt ZY
Mailiag Address of Applicant: S33"; ilx
city: '� State: Lob Zip: 9SS
Phone Number: ! 214ma :� 3
'*Pit to WQ .Lc
12-digit Parcel Number: a ra 12\ to —1 y — A o t C Lk
Approved Septic Permit Number: SWG d071 - Kh (seepage I ofdesignform)
Septic Design Expiration Date: 0 n I o r ( Z ( p g f nrm)see a e 2 o desigfo Septic Designer Or Engineer: GSA SS if (seepage I of design form)
Designer/Engineer must stamp their approval for homeowner inmiiadon,
Owner Agreement: I— — — — — e
Designer/Enpineer Stamp: '
I—the primmy owner of this nonohoreline residential property and
thiswillbemyp'hwryresidep IhaverrodaadwldersNndthe I
attached'Siamn County Homeowner OSSIMM1laaon Information,,
Iagree tofollowthe Macon CowHyprocedure,etondnrds,and
applicabk regulations dun'ng thu iwiallatton with the rmde.1a%dmg
that fad—to do so may render my drsieNpertnil void or unnsabk, I
1 �almwX I} ,I, ...as eznnxts
Signamre of Applicant/Owaer i — v - - e — e
HEALTH DEPARTMENT USE ONLY
Request Review: ❑ Approved ❑ Denied
Name of ER Specialist: INSPECTION DATES:
Signature: Pee-Imbil Meetlng:
Date:
Comments: u�Q, a�r /S D/F pePth Inspe[tlon:
'V Hnallnspection:
Th6 fwm may be senned aid available im public view an the Mason county Webst,
Updated 2/11/2021