HomeMy WebLinkAboutHOMEOWNER INSTALL APPLICATION SWG2023-00120 - SWG Application - 7/7/2023 415 N 6tn STREET,SHELTON WA 98584
MASON COUNTY SHELTON:360-427-9670,EXT.400
COMMUNITY SERVICES BELFAIR:360-276-4467.EXT.400
ELMA:360-482-5260, EXT.40D
a,Jm,os.Pn."ms.rn ,mm.ma xww,<ammunlryneann 0 FAX:360427-7798
HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: JENESSAOMDAHL Date: 7/7/2023
Mailing Address of Applicant: 100 E EMILY LANE
City: SHELTON State: WA _ Zip: 98584
Phone Number: 360-338-5792 Email:
12-digit Parcel Number: 32024-12-90061
Approved Septic Permit Number: SWG 2023-001.9�L t;kb (seepage I ofdestgnform)
Septic Design Expiration Date: 4/3/2026 (see page 2 ofdesign form)
Septic Designer or Engineer: CINDYWAITE (seepage l ofdesignform)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: I Designer/E er Stamp:
I an,file primary mvner of this non-shoreline residential property and
this will be my primary residence. I have read and understand the 4• I
attached "Mason Count).Homeowner OSSlnsial/alion Information'. I dI
l agree to follow the Mason Counry procedure,standards, and
applicable regulations during this installation with the understanding I (y ! \(�
that failure to al so m.rend n6•desigrr/pernrit void or wmsable. y°T 51
Q IND AiTe�
l Do SIONFa
Signature of Appli� kwny \ ^#t — _ _ _ _ _ _ _I
`,-, !HEALTH DEPARTMENT USE ONLY
Request Review: proved ❑ Denied
INSPECTION DATES:
Name of EH S Ciallat: �_(3
f Pre-Install Meeting: d
Signature: �(��Q Date: 7-tp
D/f Depth Inspection:
Comments: liti _ Final Inspection:
II 1 —IZ`23
60.
This form may be a ' { —z ` —Zy
Updated 9/12/2017