HomeMy WebLinkAboutSWG2020-00030 HOMEOWNER INSTALL - SWG Application - 2/10/2020 ; , MASON COUNTY 415 N 6TH STREET, SHELTON WA 98584
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4541"1:7�4` SHELTON: 360-427-9670, EXT.400
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COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
s% ELMA: 360-482-5269, EXT. 400
Budding,
Planning,
Environmental Health,Community Health FAX: 360-427-7798
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HOMEOWNER OSS INSTALLATION REQUEST
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Name of Applicant/Owner: t 11 auk I`t v 01—v‘ Date: U,Vl u/;O
Mailing Address of Applicant: Lf ;? a N
City: 1 A_c vvI eL State:
Phone Number: (a53' S I Email: (07 CAkeV CX\ ss e ' cevv\
12-digit Parcel Number: 3 d ° D 0 001
Approved Septic Permit Number: SWG 0 a O,OD d-d (see page I of design form)
Septic Design Expiration Date: 0 oZ/03 /ao,) 3 (see page 2 of design form)
Septic Designer or Engineer: PAY YDW S'9DtsC De Stn►,S (see page 1 of design form)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: Designer/EngAer Stamp:
1 am the primary owner of this non-shoreline residential property and p 4f
this will be my primary residence. 1 have read and understand the r ice - 5\
attached "Mason County Homeowner OSS Installation Information".
I agree to follow the Mason County procedure,standards, and = ., •a%•','�5ti%
applicable regulations during this installation with the understanding ,
that failure to do so may render my design'permit void or unusable.
� PAJLA JOY JOtiNSON
ExPiRittel
Signature of Applicant/Owner
HEALTH DEPARTMENT USE ONLY
Request Review: ❑ Approved 0 Denied
J_�,r INSPECTION DATES:
Name of EH Specialist: LST z l 9 -�
Pre-Install Meeting:
Signature: Date: `
D/F Depth Inspection: Z �' PP
Comments: faulk t N y,t t Fe 0( u/�d r pr.,/
3_ Final Inspection: I - °1
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This form may be scanned and available for public view on the Mason County Website. Updated 9/12/2017