HomeMy WebLinkAboutSWG2021-00227 - SWG As-Built - 5/27/2021 eJ��,�.4c•f`A^^'W- 415 N 6T" STREET, SHELTON WA 98584
? cep MASON COUNTY SHELTON: 360-427-9670, EXT.400
`I I' `° COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
ri wELMA: 360-482-5269, EXT.400
?<h Building,Planning,Environmental Health,Community Health FAX: 360 427 7798
HOMEOWNER OSS
SS INSTALLATION REQUEST
Name of Applicant/Owner: L-- ,z.y 7116 i'-,-,l n.' Date: )/1 / Z 02-7
Mailing Address of Applicant: 4/0$ - l I P-c i it)ItL e zed
City: (--r`•. ind l i State: 6.)it. Zip: 9- P /
Phone Number: 6 if- — 1 Oq_- `f 1, 7 Email:
12-digit Parcel Number: 62 0 i i -- -70" O0 O tie
Approved Septic Permit Number: SWG 2-01I-'UU Z 2-7 (see page 1 of design form)
Septic Design Expiration Date: �- `f 7$>—w 2- 1 (see page 2 of design form)
(Septic Designer or Engineer: -,,,;It1 c Jar le (see page 1 of design form)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: Designer/f eer Stamp:
1 am the primary owner of this non-shoreline residential property and 11,
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this will be my primary residence. 1 have read and understand the f P vre I
attached "Mason County Homeowner OSS Installation Information". w`4`?Sy cCA O n
I agree to follow the Mason County procedure, standards, and v--is ;, = 8._IA 14 r \\ii�
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applicable regulations during this installation with the understanding f' ) t '')
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that failure to do so may render my design/permit void or unusable. i�' CINDY 1TE �$Ii I
i LI E D,✓ SIGNER 4
a�.... qmo.. . I.....Ie..0,
✓. G i� EXPIRES 05/10t
f/� a/®/ / �� t
Signature of Applicant/Owner
HEALTH DEPARTMENT USE ONLY
Request Review: ❑ Approved ❑ Denied
l' PECTION DATES:
Name of EH Sp ialist: - I
/ ' e-InstItl'Meeting: GI 2.-2(
Signature: /! "V '��'C7 �' Date: ( J �—�
`b/F Depth Inspection: 10—
Thmments: D< inOnacgioW l�
t MAY 2 7 2021
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may be scanned and available for public view on the Mason County Website
By K Upd ited 9/12/2017