HomeMy WebLinkAboutSWG2021-00471 - SWG As-Built - 12/17/2021 7 / l p/1A, .:2-( 1
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`':El..:%,; 415 N 6TH STREET, SHELTON WA 98584
MASON COUNTY SHELTON: 360-427-9670, EXT.400
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'r� COMMUNITY SERVICES BELFAIR:ELMA: 360-275-
360-482-44675269,, EXT.
EXT.400400
�`li Building,Planning.Environmental Health,Community Health FAX: 360-427-7798
HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: JOSHUA FOSGATE Date: 12/16/2021
Mailing Address of Applicant: 4375 HAMMERHEAD COURT
City: SILVERDALE State: WA Zip: 98315
Phone Number: 360-621-7752 Email:
12-digit Parcel Number: 12218-75-00080
Approved Septic Permit Number: SWG SWG2021-00471 (see page 1 of design form)
Septic Design Expiration Date: 8/17/2024 (see page 2 of design form,)
Septic Designer or Engineer: CINDY WAITE (see page 1 of design form)
Designer/Engineer must stamp their approval for homeowner installation.
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Owner Agreement: Designer/HA'i Stamp!
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am the primal))owner of this non-shoreline r•esidenticrl property and i Q. 1I* !£,"to
this will be my primary residence. I have read and understand the air.,‘".. `t'F 11
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attached "Mason County Homeowner OSS Installation lnjbimation". ,F t , i r ,��
I agree to follow the Mason County procedure, standards, and r%� ' FZ Itl t��
regulations during this installation with the understanding o�` �r di-
applicable � I
that failure to do so may render my design/permit void or unusable. p�{ M. r �>
or I.IC , EC DE ,•, E it 1(
L' . E%Plt s t5,10,
✓-t Lt 4- i mature of Applicant Owner I
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HEALTH DEPARTMENT USE ONLY
Request Review: pproved ❑ Denied �.
INSPECTION DATES:
Name of EH S e •alist: 1 3 ���� i Pre-Install Meeting: �,—IT-2
Signature: Date:
D/F Depth Inspection: S'L�
Comments: , Final Inspection: '�
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This form may be scanned and available for public view on the Mason County a site.
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DEC 17 2021 11 Updated 9/12/2017
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