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HomeMy WebLinkAboutSWG2023-00315 HOMEOWNER INSTALL - SWG Application - 10/2/2024 OCT 0 2 2024 1 MASON COUNTY B 4L5 N " STREE SH 7-967 , E 98584 y— ^---�ricciAic 0.427-9670, EXT.400 COMMUNITY SERVICES BELFAIR: 360.2754467, EXT.400 ELMA:360-482-5269,EXT.400 Iwtldnu vbnnlyrrxiranmemal unitl�cammimiry He.IM FAX: 360427-7798 HOMEOWNER OSS INSTALLATION REQUEST Name of Applicant/Owner: NA'In0.Aj0.PA 6P,YYLA- Y Date: 0%' I(,-IQM Mailing Address of Applicant: 295` Fi Aytk4.w1 PA City: Wit BV\ State: W h zip: qK"E�J 2 Phone Number: 1--dol - �)�JFS-c)I2�J Email: VIAi S1t1M IlXy-py-P XMIAIt, 12-digit Parcel Number: 32I Approved Septic Permit Number: SWG 702-2) 003IS (see page I ofdesignform) Septic Design Expiration Date: .ry016-SS-UZ(o (seepage 2 ofdesignform) Septic Designer or Engineer: I0Lk l-104' (seepage 1 of design form) Designer/Engineer must stamp their approval for homeowner installadon Owner Agreement: I Designer/Engineer Stamp: I 1 am the primary mvner of this non-shoreline residential pivperty and I this will be my primary residence. 1 have read and understand the attached"Alason County Homeownm•OSSlnsiallalionlnfomiation". I 1 agree to follmP the A4ason County procedure,standards,mid applicable regulations arming this installation with the understanding I that failure to do so ntay render nay desigt✓su rnall Vold or unusable. a%PIREE nHalZ Signature of Applicant/Owner — — — — — — — — HEALTH DEPARTMENT USE ONLY Request Review: Approved ❑ Denied INSPECTION DATES: Name of EH Specialist: ,Pre-Install Meeti 0-4 / ` �: Signature: tl. Date: In Q-y irS-4O_ Final inspection: l 0/F Depth Inspection: Comments: �� fl' This form may be rtaaned and available for public vlow an the Mason County Webske. Updated 6/18/2018