HomeMy WebLinkAboutSWG2023-00210 HOMEOWNER INSTALL APPLICATION - SWG Application - 8/18/2023 ,t 6t Malt vviu 1 e a�
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415 N 61"STREET,SHELTON WA 98584
� MASON COUNTY SHELTON:360-427-9670,EXT.400
' ' , BELFNR:360-275-4467,EXT.400
COMMUNITY SERVICES 'ELMA:360-482-5269.EXT.400
Wadi.%P6.11,1%Environmenial' `coy•.sty FAX:360-427-7798
HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner:
Mike Roberts Date: 8/14/2023
Mailing Address of Applicant:
1540 Old Belfair Hwy
98528
City: Belfair State: WA Zip: _1
Phone Number: 206-290-3590
Email: PPrnnsulaow@gmail.com ,--
12-digit Parcel Number: 1232011201160 1 a►3 -, - Ia - O L t L0c N u6 1 `t.2023
Approved Septic Permit Number: SWG 2023-00210 (see page 1 of design form)
i By
06-01-2024 ,
Septic Design Expiration Date:
(see page 2 ofdesign form,'
Septic Designer or Engineer:
Jim Zinn' (see page 1 of design form)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: 1µ r 1
I am the primary owner of this non-shoreline residential property and , )t
this will be my primary residence. I have read !: +t and understand the r
attached"Mason County homeowner OSS Installation Information" 1 "I
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I agree to follow the Mason County procedure,standards.and . o'mtt
applicable regulations during this installation with the understanding I'$ a lot
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that failure to do so may render n,v design permit void or umisab/e. v:_sia,_,//b\----"" c.}1-"\ ------ - 1
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Signature of Applicant/Owner
HEALTH DEPARTMENT USE ONLY
Request Review: 0 Approved 0 Denied
INSPECTION DATES:
Name of Ell Specialist: — r_
Pre-Install Meeting
Date: Dl-.L2--
Signature: D/F Depth Inspection:
on:
Comments: Final inspectioKi P(S1 61r-4' bi,oeci-761-1 tw-v -3,
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Difp, 9 I, L....
and available for public view on the Mason County Website.
This form may be scanned Updated 6/18/2018
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