HomeMy WebLinkAboutSWG2022-00316 HOMEOWNER INSTALL REQUEST - SWG Application - 6/12/2023 _ i
�1"" ```kt,,, (� IE-3 T ` 41PN STREET,sHELTON WA 98584
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• ,4-sillagr.i.s.'s.). MASON COUNTY 9 LTON:360-427-9670, EXT.400
jlli :i J COMMUNITY SERV SJN 12 `?023 FAIR:360-275-4467, EXT.400
r• --�—'��3 LMA:360-482-5269, EXT.400 •
�q� • ""43",., Building,Planning,Environmental Health,Community Healtl
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• HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: T-•01( jokvi 'r'ui J J 04 i WooWeilDate:
Mailing Address of Applicant: 2VV g i'v f t - i&Its 14M11/11- I/ 1/-
City: • J 1/v1 i-rVl State: WA- Zip: oi b5 -
Phone Number: (20 ) 1 1-to %D Email: • '0`1 e, to 02-'ii KS a I1 UtiVU.
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12-digit Parcel Number: 1{-Z(' �J/ 0 n V 0 0
Approved Septic Permit Number: SWG 2 0ZZ " 1 b?j 11v (see page 1 of design form)
Septic Design Expiration Date: tD/ I i4/Z 0 g (see page 2 of design form)
Septic Designer or Engineer: Aohwt g-- (see page I of design form)
Designer/Engineer mast stamp their.appr•oval for homeowner.installation,
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Owner Agreement: Designer/Englneer•Stamp:
I am the prhnary owner of this non-shoreline residential property and QOidNal
this will be my primary residence. I have read and understand the , ;_ f trn
attached"Mason County Homeowner OSS Installation Information".
Al.....d.''' It. S! _b 1 L.
I agree to follow the Mason County procedure,standards, and � I° I
applicable regulations during this installation with the understanding• �,� "
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that failure to do so may render my design/permit void or unusable. ?t,•• `. f
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04 Annra5 J.FIU Nir .,,<,
Signature of Applicant/Owner 1•it'E'1C�>1'i5'f�1=,tc — — r
HEALTH DEPARTMENT USE ONLY
Request Review: ❑ Approved ,:1 Denied
INSPECTION DATES:
Name of EH ecialist:
r Pre-Install Meeting:
Signature: �/� J W t1 N Date:
W (0-,�eAr:JN,if L G).e,(,,„,y
Comments: D/F Depth Inspection:
Final inspection:
0/4 1/41
This form may be scanned and available for public view on the Mason County Webslte.
Updated 9/12/2017