HomeMy WebLinkAboutSWG2023-00146 APPLICATION FOR HOMEOWNER INSTALL - SWG Application - 4/28/2023 •
415 N 6TH STREET, SHELTON WA 98584
(eigh'T:-,\ MASON COUNTY SHELTON: 360-427-9670, EXT.400
'l I' F j COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
ELMA: 360-482-5269, EXT.400
Building.Planning,Environmental Health,Community Health
\ I FAX: 360-427-7798
HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: 4(? y L 4 S . keVlity Date: Z-1^ 2 7 "-'202 3
Mailing Address of Applicant: /).O_ GO}C ,R S/
City: ffe 0415 j4 Q t f State: w A •Zip: ( g 8
Phone Number:C rj(o)-- q i3°GT Email: 6/` Li c k 7 0 4 0 0,Ca-t
12-digit Parcel Number: 7 a 30 cc — 3 `1 - ? 0 d o
Approved Septic Permit Number: SWG d tJ O ' 00/ (/'‘, (see page 1 of design form)
Septic Design Expiration Date: 7Ti3 ) C'yp j3_6 ZOzd (see page 2 of design form)
Septic Designer or Engineer: - A - 'e'-i re9 (see page 1 0 .fr' t b fp)11 �7
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Designer/Engineer must stamp their approval for homeowner installation. APR 28 ?023
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Owner Agreement: �riE ! nee Stamp:
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I am the primary owner of this non-shoreline residential property and �Nri WO, - -
this will be my primary residence. I have read and understand the iv �„,'q'F1R
attached"Mason County Homeowner OSS Installation Information".
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I agree to follow the Mason County procedure, standards, and i �►
applicable regulations during this installation with the understanding " ' 1-b.
that failure to do so may render my design/permit void or unusable. o,;?t'' ' �'.7Ro::.
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A _ t-----(-1 .
• WIleti‘WA.116
ignature of Applicant/Owner
HEALTH DEPARTMENT USE ONLY
Request Review: ❑ Approved 0 Denied
i / �3 INSPECTION DATES:
Name of E cialist: ` ' IG-d (�
Pre-Install Meeting: �'�� l
Signature: • •� 6 Date:
��JJ D/F Depth Inspection:
Comments: Final Inspection: 3
This form may be scanned and available for public view on the Mason County Website.
Updated 6/18/2018