HomeMy WebLinkAboutSWG2025-00270 - SWG Application - 1/6/2026 •` ' I`a I t o bL J L, 1
'1',-,f ';.' , OCT 1 4 2025
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,.. 415 N' TH STREET, SHELTON WA 98584
, 1VF S COUNTY. _ ---- HELTON: 360-427-9670, EXT.400
. IIIIiiir COMMUNITY SERVICES-
-',_' BELFAIR: 360-275-4467, EXT.400
?A ELMA: 360-482-5269, EXT.400
dS� Building,Planning,Environmental Health,Community Health FAX: 360-427-7798
HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: 7 C C I-7 6Y y (^jar Date: I 0//6//2025
Mailing Address of Applicant: /55 CO rlvot, $Jre-CJ
City: J Ur-1- qqU State: Le_ Zip: 7,g(i)
Phone Number: ( 907) 2 " $ff?5 Email: Z<k_ L✓G/rf�/P)A�'i cti . Cc'
12-digit Parcel Number: 2_2. 131 yoo l d do
Approved Septic Permit Number: SWG 2 Q Z S — 0 62 70 (see page 1 of design form)
Septic Design Expiration Date: 7/17/2 d 2 a (see page 2 of design form)
Septic Designer or Engineer: /11/(6, fr het/ U-Cl'J U/7 (see page 1 of design form)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: Designer/E gineer Stamp:
IAA
/am the primary owner of this residential property and this will be \,tikk re Lr fl
my primary residence. I have read and understand the attached ` i
"Mason County Homeowner OSS Installation Information"and WAC' ��,. Is 4.
246-272A-250. I agree to follow the Mason County procedure, or v 11
standards, and applicable regulations during this installation with the ,' �M`�'Of 1'understanding that failure to do so may render my design/permit \‘•
I $ .1
void or unusable. b11004081
♦ MICAH THANK HA veRe0N�,�1
,` LICENSED DESIGNER ii
-.Ai illk • ' t
_EMBES•OOL161
'attire of Applicant/Owner
HEALTH DEPARTMENT USE ONLY .
Request Review: 'Ap roved ❑ Denied
INSPECTION DATES:
Name of EH ecialist: /--(1-24
/' �� Pre-Install Meeting:
Signature: Date: /— 6 I.- ��`,
D/F Depth Inspection: (Y
Comment . 0 k k 0 & 511I( 'Vtu" 'b( 1-6-2 ( r
YFinal Inspection: 2 ,zp
This form may be scanned and available for public view on the Mason County Website.
Updated 9/29/2025