HomeMy WebLinkAboutSWG2022-00396/ HOMEOWNER OSS INSTALLATION REQUEST - SWG Application - 7/27/2025 —\I Nj C-9 qa-11
415 N 6T"STREET, SHELTON WA 98584
MASON COUNTY SHELTON: 360-427-9670, EXT.400
♦ BELFAIR: 360-275-4467, EXT.400
rill" COMMUNITY SERVICES ELMA:R 360-482-5269, EXT.400
f FAX:360-427-7798
- Building Planning Environmental Health,Community Health
HOMEOWNER OSS INSTALLATION REQUEST 1. nDate: .\l /� \ \ 10-5
Name of Applicant/Owner:
Mailing Address of Applicant: 0
State: EL Zip:
l
City: ,�..-� 1Q,03
Phone Number: 7—
Email:
12-digit Parcel Number: � ` ` `
Approved Septic Permit Number: SWG 11
�n(see page 1 of design form)
Septic Design Expiration Date:
(see page 2 of design form)
Septic Designer or Engineer:
44. bA Vl•vGSL- (see page 1 of design form)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: I Designer/E :' eer Stamp:
I am the primary owner of this non-shoreline residential property and I f 44.111411
�v
this will be my primary residence. I have read and understand thet`
attached"Mason County Homeowner OSS Installation Information".
n and tion". I � • �,, 1 - �? - -Ls-
,
I agree to follow the Mason County procedure, standards, �, rr
applicable regulations during this installatio •• �/ r 6 1 tE� i ti r.. `1 -, .
that failure to 'o so . render►ip design/p ` ` �:; g� ��
�� l,4�AES R.MlM1ER c`�'.fl
' ' _ JUL 1 a 2025 LICENSED t)tSK.NER 4
1 wr• • . F� FS�.G3f42/-Z+
I �Signa r; o t cant/Ow e1y
HEALTH DEPARTMENT USE ONLY
Aproved 0 Denied
Request Review: INSPECTION DATES:�
ecialist: Pre Install Meeting: ttelt l/
Name of E p �
r
IDaE2_. !! .__
Signature D/F Depth Inspection: S
Final Inspection:
-2
Comment
This form may be scanned and available for public view on the Mason County Website. Updated 2/11/2021
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