HomeMy WebLinkAboutSWG2022-01212 HOMEOWNER INSTALL - SWG Application - 10/17/2023 _ Q\ C
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415 N 61M STREET,SHELTON WA
'~"� ''- MASON COUNTY SHELTON:360-427-9670,EXT.400
I 1 F COMMUNITY SERVICES BELFAIR:360-275-4467,EXT.400
ELMA:360-482-5269,EXT.400
Buddirxj.Planning.rnunonmei aldeathComnunnyHealth FAX: 360-427-7798
HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Owner:Daniel & Sarah Ramsey Date: 10/10/2023
Mailing Address of Applicant: 351 Yates Rd
Chehalis
City: State: WA Zip: — 98532
360-790-3863 RE C MI VZr
Phone Number: Email: sarahannramsey85@gmail.com O
OCT177(l23 L
12-digit Parcel Number: 22206-54-00041
BY.
Approved Septic Permit Number: SWA2022-001212 (see page I of design f rm)----
Septic Design Expiration Date: 03/24/2025 (sec page 2 of design form)
4
Septic Designer or Engineer: Jim Zimny (see page 1 of design
form)
Designer/Engineer must stamp their approval for homeowner installation.
Owner Agreement: I Designer/Engineer Stamp:
I am the primary owner of this non-shoreline residential property and it
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 f t tg , :I,.
applicable regulations during this installation with the understanding s++
that failure to do so may render my design.'permit void or unusable. I o I « i.'++
x tic, '.ESirnlER +
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. ‘8 %gl goe(, 7 I N.-I I
Signature of Applicant/Owner
HEALTH DEPARTMENT USE ONLY
Request Review: ❑ Approved 0 Denied
INNECTION DATES:
Name of EH Specialist: Pre-Install Meeting: )1 ` 2 i --'' 0 0, '
Signature: Date: t't 22.Z % / I
DO Depth Inspection:
Comments: _ Final Inspection: I`: -23 Pccy1it
it
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This form may be scanned and avai • ' for t:, k view on the Mason County Website. ••
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dated 9/121;201
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