HomeMy WebLinkAboutSWG2020-00068 HOMEOWNER INSTALL - SWG Application - 8/7/2023 i
6 N 8^' TREET,SHELTON WA 98584
MASON COUNTY nuc TON:360<27-
41 9670,EXT.400
COMMUNITY SER FAIR:360-275-4467,EXT,400
ELMA:360-4825269,ENT.400
1 eww,�c va��9emxamen,iuwdscam,,,�nrx.dm FAX:360427-7798
HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: a k< rC Date: 1
571 7JE TWDeAV MNj, Cvp
Mailing Address of Applicant: ,§e4Ae�aeA �* ^ - - i'
SI V,
City: State: Wr`_ zip:
Pb"e Number: -?Hp -l7Z i - 035'%>' Email: 5.1.1�al_4 1-7 L; (Z 4al also - Sidlik •..-
12-digit Parcel Number: 2 25 O.- '7<_- Gl D 1 Z-3
Approved Septic Permit Number: SWIG __d tD b;Lvy - O Oo b'8 (see page 1 oirdesign form)
Septic Design Expiration Date: �s 6 12 (seg Age 2 of design form)
Septic Designer or Engineer: 13 oh t�r�� 55c- (seepage l ofdesignjurm)
Designer/Engineer must stamp their approval for homeowner installation.
Q4enelr Agreement: I Designer/Engineer Stamp:
I am the prinuoy owner ofthis non-shoreline residential prop moo and '
thu will be my primary residence. I have read and understand the
attached"Mason County Homeowner OSS installation Information".
I agree to follow the Masan County procedµe,standards,and
applicable regulations during this installation with the understanding '
:vhoriaihtre to do so may render np,desien/permit void or unusable.
nneadr±e� re
Signature of Applicant/OnImer — — — — — — — —
HEALTH DEPARTMENT USE ONLY
Request Review: ❑ Approved ❑ Denied
INSPECTION DATES:
Name of EH Specialist:
Pre-Install Meeting:
Signature: ale% Sy7 U-24
T 0/f Depth Inspett,o¢ _ I
Comments: Final inspection: t,ilA
available tar pu c "
This form may be scanned sn
Updated 2/11/2021