HomeMy WebLinkAboutSWG2022-00339 HOMEOWNER INSTALL - SWG Application - 9/13/2023 t AA-inAkt et c �� --�
415 N 6T"STREET,SHELTON WA 98584
MASON COUNTY SHELTON:360-427-9670, EXT.400
COMMUNITY SERVICES BELFAIR:360-275-4467,EXT.400
b. l' _ ELMA:360-482-5269, EXT.400
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HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: MICHAELENGLISH Date: 09/13/23
Mailing Address of Applicant: 4280 N LAKE CUSHMAN RD
City: HOODSPORT State: WA Zip:
Phone Number: 6232614578 Email: MICKENGLISH84@GMAIL.COM
12-digit Parcel Number: 42333-51-03011
Approved Septic Permit Number: SWG SWG2022-00339 (see page 1 of design form)
Septic Design Expiration Date: 6/13/2025 (see page 2 of design form)
Septic Designer or Engineer: ADAM HUNTER (see page 1 of design form)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: 1 Designer/Engineer Stamp'. 1
I am the primary owner of this non-shoreline residential property and 1 8 2il?il
Ithis will be my primary residence. I have read and understand the 1 1
attached"Mason County Homeowner OSS Installation Informations,,. I
I agree to follow the Mason County procedure,standards,and 9/18/21
applicable regulations during this installation with the understanding 1 c. 1
that failure to do may render my design/permit v ' o nusab f,)
74.-0( 9�li I
Signature of Appli t/Owner re—
HEALTH DEPARTMENT USE ONLY
Request Review: pproved ❑ Denied
( INSPECTION DATES:
Name of EH Specialist: 1 i� 7 -�3
/ Pre-Install Meeting:
Signature: - ate: 'e._ 'I 2p
0/F Depth Inspection: •
/�1
Comments: ` Final Inspection: (a-5-7'$
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This form may be scanned and available for public view on the Mason County Website.
Updated 6/18/2018