HomeMy WebLinkAboutSWG2022-00570 HOMEOWNER INSTALL - SWG As-Built - 3/15/2023 ! U ovvv ,uG54oc/ 7° zy
415 N 6TH STREET, SHELTON WA 98584
zt .q\ MASON COUNTY SHELTON:860-427-9670, EXT.400
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' COMMUNITY SERVICES BELFAIR;360-2754467, EXT. 400
' h;^:I I tj' r ELMAI 360-482-5269, EXT.400
emldng,Panning Enr ronmental Health Commm lyHealth •��Z i FAX: 360-427-7798
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HOMEOWNER OSS INSTALLATION REQUEST
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Name of Applicant/Owner: Gary YY cbll f N ancr ga-rt a n Date: March is-; z z 3
Mailing Address of Applicant: 3 fv$I D N (A-S I-f Wy /a I
City: lJ in
i W ax fp State: WA Zip: 9 86315--
Phone Number: (3 'O) 242 - 354lS Email: VS/i ld P4 WhWwlk:h9 a7 .tc laud) , ca tx..
12-digit Parcel Number: 3 2 t'I Z 3 30 ciO O 13
Approved Septic Permit Number: SWG 2 0 L2. - 00 S 70 (see page I of design farm)
Septic Design Expiration Date: 12- - I S - 2 0Z‘ (see page 2 of design,form)
Septic Designer or Engineer: perl i'h on / 7trn 7 ra (see page 1 of design farm)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: oesiver/-Y#per stump.
1 um the primary owner of this non-shoreline residential property and • I• ttt
this will he my primary residence I have read and understand the _g:' ?by
attached "Mason CountyHomeowner OSS Installation Information". ':i�: b
I agree to follow the Mason County procedure, standards, and s
applicable regulations during this installation with the understanding �' �l1
that failure to do so may render my design/permit void or unusable, r2:'•
Signature of A •ner
HEALTH DEPARTMENT USE ONLY
Request Review: Approved ❑ Denied
9 INSPECTION DATES:
Name of EH Specialist: .�/ 4
Pre-Install Meeting:
Signature: a-C-C el. Date: /0 '-a y23
D/F Depth Inspection: q
Comments: L��-2
Final Inspection: /
This form may be scanned and available for public view on the Mason County Website.
Updated 2/11/2021