HomeMy WebLinkAboutSWG2023-00296 HOMEOWNER INSTALL - SWG Application - 9/9/2023 4,0P"'`''�`�%:tzi. 415 N 6TH STREET,SHELTON WA 98584
s c; MASON COUNTY SHELTON:360-427-9670, EXT.400
Q COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
E,,•�,�—• ELMA:360-482-5269, EXT.400
%I(t 51'7Building,Planning,EnvironmentalHealth,Community Health
11j1vn FAX:360-427-7798
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HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: 44-6 s,.rf '')Ad../ Ski en7rt, Date: V y/ 2047
Mailing Address of Applicant: --G .e /Kuy/ 2,,,,,2,,,,, '2 -,)
City: ..> 1 fva/ State: GV4 - Zip: 9Prdy
Phone Number: 24 3- 1'`f(7- 6 7 4 7 Email:
12-digit Parcel Number: 00 30. -7s- l!'U /32
Approved Septic Permit Number: SWG 2a2?_Dd 2t (see page 1 of design_form)
Septic Design Expiration Date: 71 1/ /2o26 (see page 2 of design form)
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Septic Designer or Engineer: L- r u.4 (�✓'1e (see page 1 of design.form)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: Designer„p gi Ily or Stamp: I
I am the primary owner of this non-shoreline residential property and Air 3- A.t .
this will be my primary residence. 1 have read and understand the i�o ,y +If 1. 1
attached"Mason County Homeowner OSS Installation Information". .> .l'; jc%i ,L
1 agree to follow the Mason County procedure,standards, and ii. '_ ' I
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applicable regulations during this installation with the understanding .% 5t t` \V)
that failure to do so nun,render my design/permit void or unusable. 1 C E. AITE ,01
,•, LI SED D SIGNER •i,
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�� EXPIRES 05i10/
Signature of Applicant/Owner I
ALTH DEPARTMENT USE ONLY
Request Review: Approve ❑ Denied
INSPECTION DATES:
Name of EH Specialist: _ (� ( Z3
Z� Pre-Install Meeting: (-
Signature: Date: / .2.._D/F Depth Inspection:
\., Comments: Final Inspection: /�2�zj
This form may be scanned and available for public view on the Mason County Website.
Updated 9/12/2017
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