HomeMy WebLinkAboutSWG2022-00591 HOMEOWNER INSTALLATION REQUEST - SWG Application - 1/19/2023 �Q �.zA. ,A/14 ( at(
------------7p�gj�STREET, SHELTON WA 98584
MASON COUNTY LTON 360-427-9670, EXT.400
LFAIR:360-275-4467, EXT.400
COMMUNITY SERVI h t F ELMA'360-482-5269, EXT 400
auildmS Pl°^^"'S t"`^rmmemal Neadh<ommuniy:kaab FAX:360427-7798
HOMEOWNER OSS INSTALLATION REQUEST
CHARLES EDWARDS Date: 9
/23
Name of Appdcant/Ownert
Mailing Address of Applicant:
3150 Old G-1oliack Izd
State: T� zip: "1-1TP3
City: harles P J!?4- 11a(@ {atio�.�ow
Phone Number: 2-NO Email- r/
12-d'.gi!Parcel umber:
320215804019
Approved Septic Permit Number: SWG
2022.' Q25q I _('see page I of design form)
Septic Design Expiration Date: i 7 Iat 1 jo25 (see page 2 of design form)
ADAM HUNTER (seepage I of design form)
Septic Designer or Engineer:
Designer/Engineer must stamp their approval for homeowner insta —
I Designer/ ngin e Sta
Owner Agreement: 1/19/23
I am the primary owner of this non-shoreline residential property and this will be my primary residence. I have read and understand the I I
attached "Mason county Homeowner oss installation Information
I agree to follow the Mason County procedure,standards,and
applicable regulations during this installation with the understanding
that failure to do so may render my design/Perron void or unusable.
d
l' ieaMJ NUe1eR 'Y
/ G7� i — —ia— 's44 2
Signature of Applicantiiiwner
10 - a4 - Z-3
HEALTH DEPARTMENT USE ONLY V
Approved ❑ Denied
Appr
Request Review: INSPEDki�
Name of EH Specialist: are-Install MeeDate: D/F Depth InspSignature: Flnallnspeaio
Comments: --�--
This form may be scanned and available for public view on the Mawn county Website. Updated 6/18/2018