HomeMy WebLinkAboutUntitled (2892) sOk”PIAT. 415 N 6'STREET, SHELTON WA 98584
t MASON COUNTY SHELTON: 360-427-9670 EXT.400
• COMMUNITY SERVICES BELFA{R: 360-275-4467, EXT.400
,F6 ELMA: 360-482-5269, EXT.400
;4; Building.rbnriny.Eneironmental Health.CommunityHealm FAX: 360-427-7798
•min
HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: DAVID ROSSI Date:
Mailing Address of Applicant: 21402 E STATE ROUTE 3
BELFAIR 98528
City: State: WA Zip:
Phone Number: 206-228-0957 Email:
12-digit Parcel Number: 12019-32-90020
Approved Septic Permit Number: SWG 2024-00143 (see page I of design form)
Septic Design Expiration Date: 4/28/2027 (see page 2 of design form)
Septic Designer or Engineer: CINDY WAITE (see page I ofde,sign form)
Designer/Engineer must stamp their approval for homeowner inst�''tion. -
Owner Agreement: nt:sif;n�L rlh'llt4�r Siding-is; 1
I nor the primary owner of this non-shoreline residential;woven.),and 3w• �„•Fy i
this nil!he my!Away residence. I have read and understand the 41t� -ia" St f
attached "Mason Colmt,Homeowner OSS Installation Information". ill
3� 1,tet
I agree to follow the Mason County procedure,xlnndnrds, mad "'ea sto �� f�toil
applicable regulations during this installation with the understanding f 2.dv a Gino E.es GmE�� ,a Ilt
(hat failure to do so may -ender my design/permit void or unusable. ..y il% % NI. .... s I
..
EXPIRES os min
Ow
Sig lure of Apt i It/if er - • a t
HEALTH DEPARTMENT USE ONLY
JUN 1 3 2024
-6
Request Review: 0 Approved ❑ Denied _.... . �,� _.,
J INSPECTION 0 •TES:
Name of EH Specialist: Pave- d ridPVSo
Pre-Install Meeting:
Signature: Date: ?( Z(ZOZY
g D/F Depth Inspection: Q
Comments: OWN" `�/` "r"`& cw (nil Final Inspection: ��ZI/w-�w
Zvl'
This form may be scanned and available for public view on the Mason County website. Updated 9/12/2017