HomeMy WebLinkAboutSWG2025-00242 - SWG Application - 8/18/2026 IrJI
it ID
111AUU 1 0 2025
41 THSTREET, SHELTON WA 98584
MASON COUNT i` HELTON: 360-427-9670, EXT.400
COMMUNITY SE ICES ELFAIR: 360-275-4467, EXT.400
~; ✓�.- ^,r f ELMA: 360-482-5269, EXT. 400
`i ,' Buildrng,PL0nning.Environmental Health Commun IROF FAX: 360-427-7798
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HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: 'j•cie 1 . PAN 111.- Date: (p 1 (IS IL5
Mailing Address of Applicant: L�V f 1(i e Poirck Iv D
City: EEL FAQ State: Vim► A Zip: 915
Phone Number: 951719 - `13-71 Email: lokor \q / �� emoa r C ` v v
12-digit Parcel Number: I -OW 2D
Approved Septic Permit Number: SWG ,025 (see page 1 of design form)
Septic Design Expiration Date: (see page 2 of design form)
4{Or+ ,or- ‘K.1 6'I W c
Septic Designer or Engineer: c—el n ctotZ "n-to (seepage 1 of design form)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: :�
� Designer/E���eer Stamp:
I am the primary owner of this non-shoreline residential property and
this will be my primary residence. I have read and understand the i Q
attached"Mason County Homeowner OSS Installation Information". J, • 93'tt
I agree to follow the Mason County rocedure, standards, and •
of WAsyl '�
applicable regulations during this installation with the understanding j1 : ; )' o',
that failure to do so may render my design/permit void or unusable. %,. •
Q• 5100388 3 �,
Brandon R. Jones '•.
LICENSED D SIGNER
8/14/2025
Signature of Applicant/Owner
HEALTH DEPARTMENT USE ONLY
Request Review: 0 Approved 0 Denied
INSPECTION DATES:
Name of EH Specialist:
Pre-Install Meeting:
Signature: Date:
D/F Depth Inspection: _
Comments: ivoqki (4/v t w Jr 8t✓
Final Inspection:
This form may be scanned and available for public view on the Mason County Website. r-1
Updated 2/ `J