HomeMy WebLinkAboutSWG2022-00460 - SWG Application - 10/7/2022 -E r to ,✓ i,i4 Ile el 5 '
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{ 415 N 6TH STREET,SHELTON WA 98 i,,��
MASON COUNTY t`�'� SHELTON:360-427-9670,EXT. •c o
I ` COMMUNITY SERVICES BELFAIR: 360-275-4467,EXT. 6w N
a ELMA:360 482 5269,EXT. I N
,' Budding,Planning,Environmental Health,Community Health FAX: 360-427-7 ,.
HOMEOWNER OSS INSTALLATION REQUEST -.1 1'
Name of Applicant/Owner: db. 1�‘m v-/n Date: 1011) 1,Z
Mailing Address of Applicant: l pc. a, `7`-; / peV\eW 4.)A 5 S 5 Li L,
City: Cr, t`U ce.0 k-e W State: w A Zip: 9 S 5-L{ (o
Phone Number: 3C,0-5 4 5 -36�Z Email: a0► lia 12Z0 e 54AC (• C C--,•,,
12-digit Parcel Number: '2-0 IUl 3VV'D i-0
Approved Septic Permit Number: SWG 20ZZ- 6 Q 4(o 0 (see page 1 of design form)
Septic Design Expiration Date: al Ice 1 Zo 2e (see page 2 of design form)
Septic Designer or Engineer: R 6 e C.)ay 52_e_ (see page 1 of design form)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: Designer/Engineer Stamp:
I am the primary owner of this non-shoreline residential property and 111
this will be my primary residence. I have read and understand the 1/� •a�
attached "Mason County Homeowner OSS Installation Information". 11 � ..„'
I agree to follow the Mason County procedure,.standards,and ,1N4"r ,,,,yap.
applicable regulations during this installation with the understanding 1 �1, ••
that failure to do so may render n 'design/permit void or unusable. e ' 4t , i d.w
1yv0. RO ERT H ' .SE
.1' III %II•i• 4
EXPIRES
nature of Applicant/Owner
HEALTH DEPARTMENT USE ONLY
Request Review: ....7cApproved 0 Denied
INSPECTION DATES:
Name of EH Spe • •st:
Pre-Install Meeting: /0
Signature: Date: 0-1-� (( 3 I ZZ
D/F Depth Inspection:
Comments: l 0 yU) — Afvt
Final Inspection:
1-z1-7 doLy
This form may be scanned and available for public view on the Mason County Website.
Updated 2/11/2021