HomeMy WebLinkAboutSWG2022-00262 HOMEOWNER INSTALL REQUEST - SWG Application - 5/2/2023 (.t. l- /11b52 Co---7—2 3
. 0
Mqy " 4 6TM STREET, SHELTON WA 98584
MASON COU ��` J 20 SHELTON:360-427-9670, EXT.400
� COMMUNITY SERVICES BELFAIR:360-275-4467,EXT.400
' .—; l.,' �3 ELMA:360-482-5269,EXT.400
\' ,/
Building.Nanning,Envirarmentel Health,Community Health �,
FAX:360-427-7798
c ram
HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: , 4m r t G./• g•js I`c-i's dyte: S-- 3,- z3
615I lit).S 41:50P C lO (���ld��'1
Mailing Address of Applicant: �4 •
City: y a 00 PICl 0 9 t State: 4v
Zip: "• �''- • 98,5 y
Phon
e zf3- 37D — yii/ Email: A&..,1 AKA74e,-- 4aA eui @ f 't/c.o»,
12-digit Parcel Number: P 9 2-8 - VS/ - Doo 3 c
Approved Septic Permit Number: SWG 2.e) z-'i-- 0 v di z— (see page 1 of design form)
Septic Design Expiration Date: 3=/ ` - zr (see page 2 of design form)
Septic Designer or Engineer: C 44,e,` £e sT2' (see page 1 of design form)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: '
I am the primary owner of this non-shoreline residential property and . OQ�ER EBL. ,
this will be my primary residence. I have read and understand the !� OF t. W•
attached"Mason County Homeowner OSS Installation Information".
I agree to follow the Mason County procedure,standards, and applicable regulations during this installation with the understanding that failure to do so may render my design/permit void or unusable. j1,f
O •P 28508 44 Q
��is?e.Qlsj0 •
KJ0,3--,,,,, uf,-4..._
Signature of Applir
wner
HEALTH DEPARTMENT USE ONLY
Request Review: (((((( pproved 0 Denied
� r ( r ' / I LA�,�- INSPECTION DATES:
Name of EH Specialist: —-) ,' W- - (9' °-
Pre-Install Meeting:
Date: (I-l ,-2-7—SlgIIature:9 7 / D/F Depth Inspection:
�`1(Jrli 1 �N i^f5 1Zt l�r Final inspection: 6//(1 (�Z3 t-V(�/p
-`T
Comments:
This form may be scanned and available for public view on the Mason County Website. Updated 2/11/2021