HomeMy WebLinkAboutSWG2023-00161 HOMEOWNER INSTALL - SWG Application - 6/28/2023 A 7�T�/ 415 N 6J"STREET,SHELTON WA 98584
MASON COUNTY
1 SHELTON:360 427-9670,EXT.400
0
COMMUNITY SERVICES BELFAIR:3so 275 4467,EXT.400
ELMA:360-482-5269,EXT.400
Bulking Planning.Environmental Health,Community Health FAX:360 427-7798
HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: ��'�y� V y \ Date: /2---fic/2-3
Mailing Address of Applicant: . 3 \_.C,F . 1 V_(-T\YlVNt 0\\ k "\.-
City: "-Th\\ _\. (s`.C-1. State: \, N Zip: C)\ )1j
Phone Number: ((�`) 15\-`c?)?j Email: s.'-v,p p '-I e ,yyt ( • cv,,_
12-digit Parcel Number: sC'U'• . -,(1 _ CC'•'1) iC
Approved Septic Permit Number: SWG .3 -OC1U k. (see page I of design form)
Septic Design Expiration Date: CF -C ...,--- IO`J4., (see page 2 of design form)
Septic Designer or Engineer: \Ck1P \---T k\' f,p. (see page I of design form)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: _.._ ,, ., , i „;,,1.
I'd
I am the primary owner of this non-shoreline residential properly and +
this will be my primary residence. I have read and understand the i II,
attached"Mason County Homeowner OSS Installation Information".
•I agree to follow the Mason Ctntrtly procedure,standards,and �P sy > �, I
applicable regulatio dur' this • lion with the understandingior i h °� F
that failure to a r c esixn/permit void or unusable. •f•
+
,F
9J? Da:.: _ T.A.H)A _ . ��
L' :SIGNER `ill,
Signature of ApplicandOwner ._ — . vy,
-cJl
rc
HEALTH DEPARTMENT USE ONLY
Request Review: ttliKApproved 0 Denied
INSPECTION DATES:
Name of EH Specialist: v'1L�
Pre-Install Meeting:
Signature: lJ Date: 0/F Depth Inspection: (yJ "�-'!—
S G.3
Comments; Final Inspection: vl-7-23
This form may be scanned and available for public view on the Mason County Website.
Updated 9/12/2017