HomeMy WebLinkAboutHOMEOWNER INSTALL APPLICATION - SWG Application - 10/11/2023 Ae<‘.
415 N 6'"STREET, SHELTON WA 98584
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/� '$\'' <j ; t✓r• _L MASON COUNTY SHELTON: 360-427-9670, EXT.400
�ti BELFAIR:360-275-4467, EXT.400
�� D)h- i `� I COMMUNITY SERVICES ELMA:360-482-5269, EXT.400
��' . FAX: 360-427-7798
\ / .::: Building,Planning,Environmental sealtn.Commaniy.-ea.th.
HOMEOWNER OSS INSTALLATION REQUEST
K�islcp Dher K Iv,5010.v1 Date: \0 11l2,Z
Name of Applicant/Owner: 1
Mailing Address of Applicant: ?• 0 - 3 ° X Ze' 1 (0
City: Fje l'o-\v-
State: W R Zip: 9es 2e
Phone Number:
C3(ob) IL,o- 1Z�c3 Email: \`risk ,3o6\1 c.o--f ' caw,
12-digit Parcel `umber: 1 22° S 2-1 — '00 7 1
Approved Septic Permit Number: SW G 2025 -CO 399 (see page 1 of design form)
Septic Design Expiration Date: 9 12-7/2—(42 (see page 2 of design form)
Septic Designer or Engineer: AY Yo ui S e�{-;c _le5 L v\S (see page 1 of design form)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: 1 :esign r r ee Sty —
I am the primary owner of this non-shoreline residential property and Aft
this will be my primary residence. I have read and understand the '}c � J�
attached"Mason County Homeowner OSS Installation Information". �� .- . ?�`i.
I agree to follow the Mason County procedure, standards. and I rte.2.i-f -
applicable regulations during this installation with the understanding ).. 1vt
��. SIOOJ49 � `rj`
that failure to do so may render my design/permit void or unusable. I H1 8-�' PAULA JOY JOHNSON
L Y1:_�` t
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I 1 0 — < <—t,3
Signature of Applicant/Owner
HEALTH DEPARTMENT USE ONLY
Request Review: ^ Approved + Denied
Name of EH Specialist: /�j INSPECTION DATES(:`)
"`�v Pre-Install Meeting: 7� ( `Y
Signature: Date: ��_z�
D/F Depth Inspection: ..a Comments: Final Inspector: 1 (c 31 ---Y
This form may be scanned and available for public view on the Mason County Website. .4 Ilk Ilille6
Updated 9/12/2017