HomeMy WebLinkAboutSWG2022-00459 HOMEWOWNER INSTALL REQUEST - SWG Application - 5/11/2023 415 N 6TM STREET,SHELTON WA 90584
MASON COUNTY SSHHEEtL�T�ON:360-/27-9670,EXT. 400
COMMUNITY SERVI UVI 7��'I�R�:360-2754467,EXT. 400
ffuMA:360-482-5269,EXT. 400
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HOMEOWNER OSS INSTALLATION REQUEST
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Name of Applican(/Owner: j� t� r c- Date: � Z-o i3
Mailing Address of Applicant:
City:
u 11 1n) n- �13 3 -7S State: I ) Zip:
� ,.�_�_
Phone Number: � t; �2'" 383:3' Email: i K-)
12digit Parcel Number:
Approved Septic Permit Number: SW G o�D. - -C o `1 S `1 (see paKe l of design form)
Septic Design Expiration Date: l ( /Z��i � (see page 2 of design form)
Septic Designer or Engineer: C `I SSA (see page 1 ofdesign form)
Designer/Engineer must slamp their approval jor homeomvner innallatlon.
Owner Agreement:
1 am the primary owner of this mw-shoreline residential property and I I
this will be my primary resfdenee. I have read and understand the
attached 'il4ason County Homeowner OSS Installation Infornwrim
1 agree to follow the Mason County pro"rdure,.standards,and
applicable regulations during this installation,with the understanding
that failure to do so may render my deslRN it and or unusable. _ I noeu
9ar04a5'' I
gnaturc of Applicant/Owner — — — — — — —
HEALTH DEPARTMENT USE ONLY
Request Review: ❑ Approved ❑ Denims
INSPECTION DATES:
Name of EH Alist pre-Imtall Meerin9:
Date
Signature: Date: Depth inspection:
Comments: Rini inq acnom
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