HomeMy WebLinkAboutHOMEOWNER INSTALL APPLICATION - SWG Application - 7/12/2024 415 N 6TM STREET, SHELTON WA 98584
MASON COUNTY SHELTON:360427-9670,EXT.400
COMMUNITY SERVICES BELFAIR:360-275-4467,EXT.400
ELMA:3604825269,EXT.400
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HOMEOWNER OpSS INSTALLATION REQUEST
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Name of Applicant/Owner: nt "C9L Date: y�
Mailing Address of Applicant: ; QZ IF - ge'nsea ,. P'�dq.2.-
City: z0 "v I, " State: LA9 a.. Zip: �I�S
Phone Number: :3 ]:,D _7 3 ) - t-13 a--7 Email:gkliy�c*--
12-digit Parcel Number: 7_7 ) r) �j - 1-13 - Sb '-1 O'O
Approved Septic Permit Number: SWG7,o2-Z -Ova--? (seepage I of design form)
Septic Design Expiration Date: $L J 7 Z7 _(Seepage 2 of design form)
Septic Designer or Engineer: z2 nt2 (Seepage 1 of design form)
DesignerlEngineer must stamp their approval for homeowner installation.
Owner Agreement: resigner/Iingi eer Staa'�p'.
I am toe primary owner of this non-shoreline residential property and
this will be my primary residence. I have read and understand the
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 desi¢Npermit void or unusable. oeea'.`n' wvss
JlNV� W I EXPIRES
Signature of Applicant/Owner I — — — — — —I
HEALTH DEPARTMENT USE ONLY
Request Review: phroved , ❑ Denied
t"-,�/a`--N'[/,�fl-- INSPECTION DATES:
Name of EH Specialist: �, ,�- Z
Pre-Install Meeting: r�
Signature: Date: b-07-2
i�� '�, D/F Depth Inspection:
Comments: fro. kw y.PW i• tl ZV Z�
This form may be scanned and available for public view an the Mason County Webslte. JUL 15 20,j l
Upd a /11/2021
By (SLTj�/-