HomeMy WebLinkAboutSWG2019-00350 HOMEOWNER INSTALL REQUEST - SWG Application - 2/15/2020 ar
``4, t,, ii�y� 415 N 61"STREET, SHELTO A 98584
MASON COUNTY SHELTON: 360-427-9670, EXT.400
'I i" '= COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
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, , ELMA: 360-482-5269, EXT.400
FAX: 360-427-7798
,�� Building,Planning,Environmental Health,Community Health
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HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: 0/4ST&//te& Ge/4)N64-6&.:0‹ Date: 24S"/ZDw
Mailing Address of Applicant: Z3 V E t 1 t/1-G f/,6lGL
City: 66E1FTh,Z Statt: r-t/4 Zip: 9fr_S
Phone Number: 3(r) /()(-36 Z i Email: PAW. xcA-Vi4Ti/ i C) Sc160Q,eali
12-digit Parcel Number: ?_Z-ZZ L/—7th -00'130
Approved Septic Permit Number: SWG of —QD 3S 0 (see page 1 of design form)
Septic esign Expiration Date: / �l �ZZ (see page 2 of design form)
Septic D signer or Engineer: (nu by tAl 4 1 r (see page 1 of design form)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: De ,g„`, c Is , .. I
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I am the primary owner of this non-shoreline residential property and I
this will be my primary residence. /have read and understand the ��c. ; ildi
attached"Mason County Homeowner OSS Installation Information".
I agree to follow the Mason County procedure, standards, and 10%, s. , •
applicable regulations during this installation with the understanding ?P O=tO 't+40 ,1�, f
that failure to do so may render my design/permit void or unusable. 41 I
• i \\".
I I
r of Applicant/Owner
HEALTH DEPARTMENT USE ONLY
Request Review: 0 Approved 0 Denied
J INSPECTION DATES: J
Name of EH Specialist: ��� ��1 v_z 0 k —•
Pre-Install Meeting:
Signature: Date: f — �� -2-'// D/F Depth Inspection:
Comments: l(i' l`4.hla e o'- ),4t 51v7'vO\ Inspection:Fir* ( t4 3 -( "\-0t7 VO r4 a\--t
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This form may be scanned and available for public view on the Mason County Website.
Updated 9/12/2017