HomeMy WebLinkAboutSWG2021-00009 HOMEOWNER INSTALL - SWG Application - 8/22/2022 p : t 7`1 �'
415 N 6TH STREET,SHELTON WA 98584
MASON COUN A�G 2 3 pp22 SHELTON:360-427-9670,EXT.400
COMMUNITY SERVICES 9ELFAIR:3e0-2754467,EXT.400
ELMA:360-482-6209,EXT.400
BUYarp VYmig.Eneronm�aalNWih[ erswry._--_ FAX: 360-427-7798
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HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner: Patricia Gneiding Date: 8/22/2022
Mailing Address of Applicant: 5046 Onalaslap Loop SE;
City; Port Orchard State: WA Zip: 98367
Phone Number: 360-979-0551 Email: patriciagneiding@gmaii.com. _
12-digit Parcel Number: 12320-10-03240
Approved Septic Permit Number: SWG 2021-00009 (seepage 1 ofdesiggform)
Septic Design Expiration Date: 01/14/2024 (see page 2 ofdesignform)
Septic Designer or Engineer: Tom Weaver/Allied Design Inc (see page 1 (?fdesignform)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: I Designer/Engineer Stamp: I
l am the primary owner of this non-shoreline residential proper0,and I I
this will be my primary residence. 1 have read and understand the
attached "Mason C'oun0,Homeowner OSS installation lnftxmarion
1 agree to follow,the Mason County procedure,standards. and
applicable regulations during this installation with the understanding ( f
Char failure to do so may render m-des) n/ e @
i permit void or unusable �..,
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Signature of App icant/Owner _ — — — — — —
HEALTH DEPARTMENT USE ONLY
Request Review: Approved ❑ Denied
Name of EH / INSPECTION DATES-
Signature:
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Comments- � 5 Ao4- I � C4 - L2- ,Y3 o/FDepthlmgctbn:
Final Inspection:
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This form may be scanned and available for public view on the Mason County Website.
Updated 6/18/2018