HomeMy WebLinkAboutSWG2019-00025 - SWG Application / Design - 12/26/2019 au, (,,J 2.- zO - 2.0
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DEC 2. `� 2019 • 5 N 6T"STREET, SHELTON WA 98584
MASON COUN SHELTON: 360-427-9670, EXT.400
;•` " COMMUNITY S VICES BELFAIR: 360-275-4467, EXT 400
_J=:. - -- ELMA: 360-482-5269, EXT.400
Building,Planning Environmental Health.Community Heahh FAX:360-427-7798
HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: r AC,4- \" A- - - AO S#re)r-s Date: 12.-fo'(C
r Mailing Address of Applicant: '1 31 A./ Pk` a1'it-t- - `
City: -, (-' State: V� Zip: 9 S SZ$
Phone Number: (! oO) 2:1 S- 9 b S Z Email: I \YYNQ OS'it-W.r R WNR...CZP A
12-digit Parcel Number: l 23 2-'i — 23-• /OO4-t
Approved Septic Permit Number: SWG 20 IS - O-OO ZS (see page 1 of design form)
Septic Design Expiration Date: 3 -S-Z Z (see page 2 of design form)
Septic Designer or Engineer: `-Clo� k 3 \Vs a\ (see page 1 of design form)
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Designer/Engineer must stamp theirapproval for hoi�t�owner installation.
Owner Agreement: Designer/Engi:yeer Stamp:
I am the primary owner of this non-shoreline residential property and {
this will be my primary residence. I have read and understand the
attached"Mason County Homeowner OSS Installation Information". �-'... • •• �.
I agree to follow the Mason County procedure.standards, and �.�� tio1 v4,, rc+.
applicable regulations during this installation with the understanding Ic
that failure to do so may render my desin/permit void or unusable.
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Signature of Applicant/Owner
HEALTH DEPARTMENT USE ONLY
Request Review: 0 Approved 0 Denied
INSPECTION DATES:
Name of EH Specialist: a� O 14'
Pre-Install Meeting:
Signature: Date: —3-5D/F Depth Inspection:
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Comments: / we or-re c i-- Final Inspection: l 4
IS(ANtt' ° C4.t,r‘ P4u'it, br of„, 04/A, 1 Aiv L-f Z
This form may be scanned and available for public view on the Mason County Website.
Updated 9/12/2017