HomeMy WebLinkAboutSWG2004-00063 - SWG Application - 2/12/2004 ON-SITE SEWAGE SYSTEM PERMIT p
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MASON CO�IN PERMIT NO. SWGTY DEPARTMENT OF HEALTH SERVICES -- — -,.-- `-� ` L)iL � D
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426 V1!. CEDAR/P.O. BOX 1666/SHELTON, WA 98584 Date �� (� C: Cn
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PHONE (360) 427-9670 Receipt No. - oCn
Amount$ z —i
P PERTY OWNER— �. DATE: _ _Q ✓ 3
G CHECK APPLICABLE ITEMS m
S D I E P _ NEW SYSTEM
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TABLE 6 REPAIR 'U
CITY: STATE: ZIP: m
MAINTENANCE REVIEW
PROPERTY A RESS: SINGLE FAMILY Z
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SP IFIC DIRECTION6 FOPOCATING SITE: PRIVATE WELL
COMMUNITY WELL/PUBLIC SYSTEM 4 '�
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SYSTEM NAME
APPLICANT
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Name o Lot J ft.x ft. MAI ING ADDRESS ,c,
Installer — Va �
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OFFICIAL USE ONLY LOW IS LINE
DEPARTMENTAL SOIL LOGS DEPARTMENTAL COMMENTS/CONDITIONS
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SOIL TEXTURE CODES: 3 Z _
V=Very G=gravelly S=sand L=loam Si=silt C=clay E=Extremely
INSPECTOR(print name) INSPE ION SIGNATURE DATE PERMIT XPI TION DATE
•All systems require ongoing Operation and Maintenance(O&M)as specified in Mason County On- ke Standards.
•All on-site sewage systems must be designed by a Mason County Certified Designer or a Professional Engineer,unless prior approval is granted otherwise
•All on-site sewage systems must be installed by a Mason County Certified Installer,unless prior approval is granted otherwise.In such cases a preliminary on-site
meeting between health department staff and the homeowner is required.
•On-site sewage system design approval does not imply other building site requirements(i.e.RLC,Water Adequacy)have been met.
•Any change from the specified use of the property or any site alteration affecting the system design may invalidate this permit.
•This permit ex Tres 3 ears from the date of site review.Denial of this permit may be appealed to the Health Officer within 10 days of denial date.
DESIGN REVIEW AP OVAL BY: DATE: I AL TION PROVED BY: DATE:
TOP: Health Dept. Copy MIDDLE: Designer's Cleply BOTTOM: Applicant's Copy
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