HomeMy WebLinkAboutSWG2023-00410 HOMEOWNER INSTALL - SWG Application - 2/1/2024 415 N 6TH STREET, SHELTON WA 98584
I MASON COUNTY SHELTON:360427-9670,EXT.400
COMMUNITY SERVICES BELFAIR: 360-2754467,EXT.400
�i&M.Plennyq Fmimnmenal Neel�h Camm�niryHWM ELMA:360-482-5269, EXT.400
FAX:360427-7798
HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: 57axt =e�1MDS Date: ZI11,2Y
Mailing Address of Applicant: sVO BOX 2355-
City: `aECe1! State: wpir Zip 9$Soo
Phone Number: rs�.O�i-39/� 7Si �es� Email: a&kk c \v�yS�g Df'Yl
12-digit Parcel Number: --3nq�A OOrjC� U V
Approved Septic Permit Number: SWG Z02'3 — M H18 (seepage I ofdesignform)
Septic Design Expiration Date: p.,� y� p��� (seepage 2 ofdesignform)
Septic Designer or Engineer: 7 Al f7 QV"A A ,-V r o (see page 1 of design form)
DesignerlEngineer mast stamp their approval for homeowner in allation.
Owner Agreement: I Desl !. - eer S[,,l,
I am the primary owner of Phis non-shoreline residential property and �-
thiswillbemyprimaryresidence. Ihavereadandunderstandthe "^r.(>°y�,
attached"Mason County Homeowner OSS Installation Information
I agree tojollow the Mason County procedure, standards, and
applicable regulations during This installation with the understanding I s+oa>as no
r-
th NtHONY pWEN OEM1NE
at failure to do so may render my design/permit void or unusable. s.i� N ti 4 N xi
� iIgnature of Applicant/Owner — — — — —
HEALTH DEPARTMENT USE ONLY
Request Review: Y-Approved ❑ Denied
INSPECTION DATES:
Name of EH Specialist: \ ' �I'�n D • 1
•�_lCn ' — Pre-Install Meeting:
Signature: yl 1 " -/V�` Date: :� Il�lZy
D/F Depth Inspection:
f Comments: 7Yd��J� r{' �,e_{j/ 1 `— Final Inspecoon:
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This form may be scanned and available for publicview W the Mason County Website.
Updated 2/11/2021