HomeMy WebLinkAboutSWG2023-00244 HOMEOWNER INSTALL - SWG Application - 7/14/2023 C 1 ®ll �
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04DIs°-r''t:',,e. 415 N 67"STREET, SHELTON WA 98584
4 MASON COUNTY SHELTON:360-427-9670, EXT.400
.II- .L COMMUNITY SERVICES BELFAIR:360-275-4467, EXT. 400
„' ELMA: 360-482-5269, EXT.400
`:: Building,Planning,Environmental Health,Community Health
e e. FAX: 360-427-7798
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HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: L1,-a-aQ- - k-1/41K L S
Date: 7- (`k'Z�
Mailing Address of Applicant: 27 S 3'F 74N `Cs-r- `p(.• IQ W
City: `C 0 L-L_ S b o State: 1J Y Zip: cl "837 0
Phone Number: (3c0o) GSS- IS 0 Email: S '`Te` 'I 1 Id K, @7)--sr.".oa\,c
12-digit Parcel Number: 120 l'8 - -1 S- ODO I 0
Approved Septic Permit Number: SWG ZO 2-S - DO Z`f (see page 1 of design form)
Septic Design Expiration Date: Co - Z(- 2(0 (see page 2 of design form)
Septic Designer or Engineer: �G.�,,S_ .-o -—S D k (see page 1 of design form)
� Se-t13- -c. `.cam S c,
Designer ngineer must stamp their approval for homeowner installation.
Owner Agreement: — —
Designer+?`t,eer Stt.nnp:
I am the primary owner of this non-shoreline residential property and •r,
s�
this will be my primary residence. I have read and understand the � �'��
attached"Mason County Homeowner OSS Installation Information".
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I agree to follow the Mason County procedure, standards, and ► ••�•S t ,! ,applicable regulations during this installation with the understanding I ... •..-q
that failure to do so m rende v design/permit void or unusable. t-(� •
51003e9
.t? PAULA JOY JOHNSON• `
1.
EXPIRE? 1i
SignCik e o icant/Owner _ �5
HEALTH DEPARTMENT USE ONLY
Request Review: Approved ❑ DeniedVV�f ^ rr
Name of EH Specialist: �' � VZ�
INSPECTION DATES:
�� Pre-Install Meeting: 7. '-(` �)
Signature: Date:
D/F Depth Inspection:
Comments: f 145er it✓2 /V") ba---k-r.e S
/ Final Inspection: l�t`�Y
�� 4-6C div4-1140(-, e it_f 7F'`
This form may be scanned and available for public view on the Mason unty Websit 0 1 70 `4 lb
4—/ Il Lr sited 9/12/2017
///���/ n O C T 11 2023
By_____ _L •