HomeMy WebLinkAboutSWG2021-00201 HOMEOWNER INSTALL REQUEST - SWG Application - 8/29/2024 - V 415 N 6Th STREET,SHELTON WA 98584
:_ MASON COUNTY SHELTON:360-427-9670, EXT.400
COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
.�" ELMA:360 482-5269, EXT.400
\' Building,Planning,Environmental Health,Community Health
FAX:360-427-7798'
HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: P.3---U--5 L$t ( \JACK ...L.."-) Date: S-(2 ( i--)-
Mailing Address of Applicant: 1 EJ 1 5Pr i' b_-J et
City: a4kKA State: W P Zip: ' sy t
3(1)-5550--5S1-4-1 e ei s eiNs i���a VAR'L•Card\
Phone Number: Email: `� `J
12-digit Parcel Number: (_ (q 05-- i' I O
Approved Septic Permit Number: SWG Z 02.1 - C702.®', (seepage 1 of design form)
Septic Design Expiration Date: 411 j l Z.OZrO (see page 2 of design form)
Septic Designer or Engineer: Ci/ft/s eGpj1eO (seepage 1 of design form)
Designer/Engineer must_stamp their approval for homeowner installation.
Owner Agreement:g Designer/Engine-rt,m.:
I am the primary owner of this non-shoreline residential property and { ,g9,ES yN
tstthis will be my primary residence. I have read and understand the r Lay?,'. {
attached "Mason County Homeowner OSS Installation Information".
I agree to follow the Mason County procedure,standards, and gs ,I ' I
applicable regulations during this installation with the understanding , 2 � KK
that failure to do so may render my design/permit void or unusable.
946 0 28508 69 , a`°
06'5�ISTst-,e-
Signature of Applicant/Owner
HEALTH DEPARTMENT USE ONLY
AUG•2 9 2024
Request Review: pproved ❑ Denied Dv _
IN ' ON DATES:
Name of 31t:
t: '�
Pre-Install Meeting: ✓--- g -�
Sigma ure: LI
Date: 11,-A
D/F Depth Inspection:
Z
Comments q---__
Final Inspection:
This form may be scanned and available for public view on the Mason County Website.
Updated 2/11/2021