HomeMy WebLinkAboutSWG2019-00528 HOMEOWNER INSTALL REQUEST - SWG Application - 5/15/2023„..............1
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415 N el STREET,SHELTON WA 98584
MASON COUNTY SHELTON:360-427.9870.EXT. 400
141 .1 I COMMUNITY SERVICES BELFAIR:360-275-4487,EXT 400 ..
ELMA.360-482-5269,EXT.400. .,“,,,,A1' ..otytke.,:th FAX.360-427-7798
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HOMEOWNER OSS INSTALLATION REQUEST
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Name of ApplicantiOwner: ticrt$ k,../ v „Af i 5
Date:
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Mailing Address of Applicant: 2e7 7 1 A I‘., c tc-tk- t fie€
('its: State: VIR- Zip: e'e:, 8 .)
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Phone Number: 3/a: - Fri 21;7 Email; ekv-L 4 t,j c ..,,1 (cki ke-tryv.4 i • (0:-,
12-digit Parcel Number: ?)2:") ,1 - -74— — C)00S—t)
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SW C 201C1 — CO 1 2-e N
Approved Septic Permit Number:
(see page 1 al design'arm).
Septic Design Expiration Date: [- I;- Z 7) !see page 2 of dattn farm,
Septic Designer or Engineer: P4\Ai IA Jo jun 56*” (Ave page I of design fbrnti
Designer/Engineer must stamp their approval jar homeowner installation.
*. Owner Agreement:
I am the,primary owner(Oho non-shoreline riidentiul property and
this will he my primary residence. I have read and understand the
attached"Maxim Coway Homeowner OSS Installation Infant:anon . ,
I agree toollow the Mason County procedure. stmulards, and , •to!ir,,,,16, •
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,ipplieahk regulations during this installation t.iilt the understanding
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th01 failure ti,sto so nn-render nn,desiew permit void or amicable • . ,
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r:• PAULA JOYesti.4.11. iNirt;.....l‘i..;5
•I'' CA-A,/NC__ Pk .
Signature of Applicant/Owner ,--- — - --MAY 2 0,2020
., • HEALTH DEPARTMENT USE ONLY
Request Review: 0 Approved i.:1 Denied ,..., ,,, .
INSPECTION DATES:
• \ante of EH Specialist: ... _
Pre-Install Meeting. (:—1 5.1-- 4 0173(-eV
Signature: Date:_ __ _ :
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0/F Death Inspection- ) —21. v,:i —
.. A-1. 4.405 Ard4 LI"( kr Comments: Dttife..__G—.4'al
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final Inspection:
I d Ve efi 41/4/ 2„,_ ha AI 001 19kvii_
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This form may be scanned and available for public view on tto Mason County VJebsite, 0 mcmEvt,
cm9/ 2/2)17
II ii MAY "IV020 LVJ
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