HomeMy WebLinkAboutSWG2022-00183 HOMEOWNER INSTALL - SWG Application - 8/23/2022 1 t%
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Health
- " Building,plann^g,Environmental Health Community _' Ir
HOMEOWNER OSS
INSTALLATION REQUEST Date: .v ti Z
Name of Applicant/Owner: S�
Mailing Address of Applicant:
� 3$ $� Zip: G185 Z
State:
City: 9 Email:
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p o o 7 C��
Phone Number: _ 50
page 1 of design form)
12-digit Parcel Number: 2Z _ 0��$'3 (see
page 2 of design form)
Approved Septic Permit Number: SW _ (see
1 2' form)Septic Design n Expiration Date: ` � �l\ S (see page 1 of desig►1f
Designer or Engineer:
Septic Desig their approval for homeowner installation. _._. .....
aineer must stamp
Designer/Engineer I"� Designer l:ineer Stanp'
Owner Agreement: and ��" � ��
i
this non-shoreline residential property --^� ), I
primary owner of . _
I am the P �'� �' •
'"'.': 1
this will be my primary residence. 1 have read and understand the
Homeowner OSS Installation Information". =� r • r
attached"Mason County procedure,standards, and a •� -•I, 3 .4 . 1
I agree to follow the Mason County p 1 ;' S100349
lotions during this installation
with the understanding
g 5 PAULA JOY Jo:INSON
that'applicablefailure regulations �'• tC1 6>=:1°349 GN ...t
render my design P
that to do so mayI ac>��Es yito� '
I �'2� 22•
Signature of Applicant/Own+er
HEALTH DEPARTMENT USE ONLY
'Ir pproved ❑ Denied INSPECTION DATES:
Request Review:
Pre install Meeting: �`c} s
Name of EH S ecialist: �r�J
Date: D/F Depth Inspection:
Signature: Final inspection
Z7 Z
1 Comn►ents: ,
Website. Updated 9/12/2017
1
This form may
be scanned and available for public view on the Mason County