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