HomeMy WebLinkAboutSWG2022-00183 HOMEOWNER INSTALL - SWG Letters / Memos - 8/23/2022 s a d 11
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MASON COUNTY . ;
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til"f COMMUNITY SERVICES •• 360-482-52��,< XT i
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-Building,Planning.Environmental Health.Community Health
HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: �c s �-4. ,r,A.,'"`°'-s e. Date: 6'I-- Z2
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Mailing Address of Applicant: 3S i s >e SU3
State: WIT Zip: i 8'S(2
City: (�`-'� ,
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Phone Number: (3b �
o) 9 l% � o Z Email:m ail: �Scr1�.e � C,+�.-7
12-digit Parcel Number: Lk Z l �' �'
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Approved Septic Permit Number: SWG 242_2- - O0VS3 (see page 1 of design form)
Septic Design Expiration Date: 4 —7- 25 (see page 2 of design form)
Septic Designer or Engineer: ANMCNA.D S,4_,,p`*c_ .eS‘ (see page 1 of design form)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: Designer 'i+:sneer star,c:
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I am the primary owner of this non-shoreline residential property and �,; ' ,
this will be my primary residence. 1 have read and understand the 0,�� J,
attached"Mason County Homeowner OSS Installation Information". F,.
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I agree to follow the Mason County procedure, standards, and " \ .
"applicable regulations during this installation with the understanding E 'r 3
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that wit
failure to do so may render my design/permit void or unusable. Li ' 51.0349 PAULA JOY J0 !NSON •'3f•
Q�(� SI r fOCR ESZI %1$/L��
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Signature of Applicant/Owner
HEALTH DEPARTMENT USE ONLY
Request Review: Approved ❑ Denied
INSPECTION DATES:
Name of EH Specialist: (,i.y'j
Pre-Install Meeting: '
Signature: Iatyltitia Date: (-2_Z"� D/F Depth Inspection: 1 CrLv��S
Comments: i Final Inspection: I Z7--Z-
This form may be scanned and available for public view on the Mason County Website. Updated 9/12/2017