HomeMy WebLinkAboutSWG2024-00282 HOMEOWNER INSTAL - SWG Application - 8/26/2024 415 N 6m STREET,SHELTON WA 98564
MASON COUNTY SHELTON: 360-427-9570,EXT.400
COMMUNITY SERVICES BELFAIR:360-275A467,EXT.400
ELMA: 360-462-5269.EXT.400
Mrow:p(m..mn.ryYnwlshcommwJry N.YN FAX:360-427-7798
HOMEOWNER OS1S INSTALLATION REQUEST,
Name of Applicant/Owner: ArAn�4 �� �1 p. '{�I�1 U� Date: �IM 2o2.,t"f
Mailing Address of Applicant: I0� F, Lov Lw I*-
City: r )V LS'lh)L" --.p State: u y t i'— Zip: M- r-0 L I
3LeD "D '2:1101
Phone Number. ��a� Jrb____ Email:
12-digit Parcel Number: 7 2,0 Zq 5n Dn()u 3
Approved Septic Permit Number: SWG 2D24' D 0 a 2. (seepage i ofdesign form)
Septic Design Expiration Date: (seepage 2 of design form)
Septic Designer or Engineer: IC�1 l (seepage I ofdesignform)
Designer✓Engineer must stamp their approval for homeowner installation.
Owner Agreement: I Designer/En ineer Stamp:
I am the prinni owner ofthts non-shoreline residential properly and \
this will be my primary residence. 1 have read and understand the
attached"Mason County Homeowner OSS installation Information
1 agree to fohow the Mason County procedure, .standards,and I '\
applicable regulation during this installation wilh The understanding
Mat fothue to de so nap render my design/per..it void a unusable. m m
sic
um
snEa e IGNER
S' nature of Applicant/Owner I — — — (M
HEALTH DEPARTMENT USE ONLY AUG 29 2024
Request Review: Approved ❑ Denied
INSPECTION DATES:
Name of EH S mlish.
y2� D/FDPre rtthinspeall cti
Signature G _ Date: q-/ D/F Depth Inspection.
Comments. Final Inspection: yJ�Y
This farm may be scanned and available for public view on the Mann County Website.
Updated 2/1I/2021