HomeMy WebLinkAboutSWG2022-00250 HOMEOWNER INSTALL - SWG Application - 7/11/2023 cric
'ea\
'2',
415 N BT"STREET, SHELTON 6564
1 , MASON COUNTY SHELTON:360-427-9670,EXT 400
1 ) COMMUNITY SERVICES BELFAIR:360-275-4467,EXT.400
e.wmaereoo+nn.ee+un,hew"e+m.comrn,.niy Health ELMA:360-082-5269,E%7.400
�'n• FM: 360-427.7798
HOMEOWNER OSS INSTALLATIONQ REQUEST
Name of Applicant/Owner: \c(XISb u1 Buff OD-ktt-IQ5 Date: 7111 (doa3
Mailing Address of Applicant: Lit.O E. MAst n Lake... Or. S .
City: Ca COT esito State: U3A- Zip: j $59
Phone Number: 3(00• bel)-'7'e9 li Email: S1GC_tr1'trarO�, 4M0.it.c n4
12-digit Parcel Number: 22t OL.I,i-{3 .So I DO all
Approved Septic Permit Number: SWG a0 eta — 0 0 a5C (see page 1 of design form)
Septic Design Expiration Date: Si 3/ 20,2 S (see page 2 of design form)
Septic Designer or Engineer: C4hfita H. ?allmor 3 AS 30t_. (see page I of design form)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: In Designer/ ineer Stamp: •
/am the primary owner of this non-shoreline residential property and
this will be my primary residence. I have read and understand the
attached"Mason County Homeowner OSS Installation Information".
I agree to follow the Mason County procedure,standards, and ) •
fesit,
applicable regulations during this installation with the understanding / m
that failure to do so may render my design/permit void or unusable. 6aoo2os
.CHARtES a. POLLYAR
in✓ten' ✓/V We+'r✓. IXo�wry
.•
Signature of Applicant/Owner •
HEALTH DEPARTMENT USE ONLY ^
•
Request Review: pproved 0 Denied - -�/ -
t�Fi
c/1 117 j INSPECTION DATES:
Name of EH Specialist: V V —�j/
Pre-Install Meeting:
Signature: Date: 1-6 D/F Depth Inspection: -2
Comments: C' , 5'-13
Final Inspection:
D4 St( ( A -c
This form may be scanned and available for public view on the Mason County W ebsite.
Updated 6/18/2018