HomeMy WebLinkAboutSWG2019-00436 HOMEOWNER INSTALL REQUEST - SWG Application - 7/28/2023 415 N 6TH STREET,SHELTON WA 98584
MASON COUNTY SHELTON:360427-9670,FXT.400
l OMMUNITY SERVICES BELFAIR:3 6 0-27 5 4 4 67,EXT.400
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ELMA:360-4825269,EXT.400
FAX: 350427-7798
OMEOWNERO"SS INSTALLATION REQUEST 7
ppH �\0.1Y\0.�`/1 Oak es Date: Vl Zo 2p .
Name of A hcant/Owner: w � y
Mailing Address of Applicant: ,� I V S 011.' ✓iAQ¢ b Yp.����/
City: 21-ftz.l✓ State: � Zip:
Phone Number: 37Z� 58� ` ,�-�E7��/ma a frYtt�. cBrh
12-digit Parcel Number: 3 222(0- ' `eP nnAa, C) C)
Approved Septic Permit Number: SWG +2-Ot9 — 0045(P (see Page 1 of design form)
Septic Design Expiration Date: ,----1 -,Lb _ (seepage 1 of design form)
Septic Designer or Engineer: YVD iQ C 0 i2S t vl°oee page I of design form)
Designer/Engineer must stamp�eir approval for homeowner installation.
Owner Agreement: \ ' 0esl8ner/En Stamp:
I am the primary owner oftha non-shoreline resideIzo rty and
this will be aty primary residence. 1 have read and tattached"MoronCountyHomeownerOSSlwtallat fasson d �h
large to follow the Mason County procedure,stun ,and.
applicable regulations during this installation with the understanding\
'
thm,failur do so render my d it void or unusable.
paULa JOY JOHNaON `.
Signature of Applicant/Owner J-- — — — — — — —I
HEALTH DEPARTMENT USE ONLY
Request Review: v C Denied
!!! J INSPECTION DATES:
Name or EH Specialist:
pre-Install Maetin{:
Signature: Date: I G• -2.
D/F Oepth InspeNpn: 1(��✓E
Comments: Final lnapection:
This form may be scanned and available for public view on Me Mason County Website.
Updated 9/1 017
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