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HomeMy WebLinkAboutSWG2024-00414-HOMEOWNER INSTALLATION - EH General - 10/9/2027 f STREET, SHELTON WA 98584 ��^��'"�v Q '-���� `:LTON: 360�27-9670,EXT.400 '` 'c„ MASON COUNTY -! FAIR:360-275-4467,EXT.400 COMMUNITY SERVI ! V 1 4 2[024+ .y ELMA: 360-482-5269,EXT.400 ��I• � FAX 360-427-7798 '�f Environmental Health Community Health .� � Building Planning.��_>>.�, ,�.� BY: OWNER OSS INSTALLATION REQUEST HOME f -, Date: �q I r1 �G�� )� Name of Applican#/Or:- Y{-hu'- Mailing Address of Applicant:City: �1{'�� I--W State: _ Zip: `7 b Phone Number: )_ (�/ . � Email: ^ r.:^e. i vi 2 12-digit Parcel Number: ' \I - " Do10 Approved Septic Permit Number: SWG 20Zh p 4 1 q (see page 1 qf design form) Septic Design Expiration Date: 1 o / ©R / 2 7 (see page 2 of design form) (see page 1 cif design firm) Septic Designer or Engineer: Designer/Engineer must stamp their approval for homeowner installation. Designer/Ener Stamp: Owner Agreement: 8/am the primary owner of this non-shoreline residential property and �'' residence. I have read and understand the ,c 46) this will he my primary t-. attached "Mason('ountyHomeownerOSSInstallationIformation". �� •�,h�., • fil l agree to follow the Mason County procedure, standards, and . tF i;. l` • I .� applicable regulations during this installation with the understanding • 4 �>� ��.�' SIOJ749 that failure to do so may render my design/permit void or utilisable. y�* PAULA J01 JOHl. NSON I • E)tPfIiFS ` Signature of Appli ant/Owner I mom' HEALTH DEPARTMENT USE ONLY ),roved 0 Denied Request Review: I INSPECTION DATES: TE Name of EH Specialist: Pre-Install Meeting: ` 24) ate: `t 't-4 _Inspection: _l�_�__�_72f Signature: D/F Depth t_i__ ___).5 final Inspection: Comments: This form may be scanned and available for public view on the Mason County Website. 'Updated 2/11/2021