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HomeMy WebLinkAboutHOMEOWNER INSTALL REQUEST SWG202300334 - SWG Application - 7/29/2024 416 N 6�"STREEI,SWLT©N WA"664 MASON COUNTY SWELTON:360-427a96/0, EXT,4 ` COMMUNITY SERVICES RELFAIR:360-275-4467,EXT.400 `i � EL-MA:360-462.6209,EXT.400 i. &ArflQ.SdFfl1114,thvikkitiehtilNldht4tommtiolwnogul FAX:360-427`7706 HOMEOWNER OSS INSTALLATION REQUEST ��./ IL r Q-11 Sin o ;y Z _ Date; 7 ' 2 ?/ 2-°� Name of Appliaant�wnert .� _-- Mailing Address of Applieanti 333.3 e-- 1---ia s/, 2 le eL S Cityt SA 1 .' State: Z--)4. Zip: `l es- Phone Nuinbea•: _ -2S3- S7q- 3!r,7_ Email: 11-digit Parcel Number: , 12a?cD -23- o' SO Approved Septic Permit Number: SWG 202 3 -00 3,ye (see large l of design form) Septic Design Expiration Date: Fr 2 Z/ 2.t5 2-1 (set'page 2 of design form) Saptia Designer or Engineer: 6^-I,e ► __.._W Q'k (see page I of design form) #em a ng#n+�ar muff stomp their approval for hone owner installation. Owner Agra@inailti Design�f.t1 linior Stump: r e1 1€##H the prftiun'mew O(thi r haft4hiiioline residentioi property and s, t .),ith this twill he my'H''Wool y�!'c ifanee, i haw rood Ellin understood the 1 9, 1 Httoetted"Moon Coo�y Hammy/tor O Wm/kW information". �"' + /y; `4e, I agree tn./biltlw the itMritbn Como;pi' r►iiie,st�rnrkireis, owl „, 4.' 11,�� ppIk' ip► m/Mans(Awing this itotoilitttnit with the undemanding 5 ro?8 `'1` `� th(t failure to Coif,ttl tow!h i` �►design/permit void or Nl/illCible, LICENS z• •• SIGNER 111 Illi'•101016. AM IlibliiIM. Ilk %% 1 EXPIRES 05,10/ Ailf;— -/' '' / Signature of A plieant/Owner .IIIMM _ MI' '1(11= sawn / HEALTH DEPARTMENT USE ONLY Request Review: Approved d Denied INSPECTION DATES: Name of Eli gpeeinlisti l(-Z ?� pre-ln%tdtl Meeting: Signature: - 1Date: ' 7 ''r DX.�r t t C ®flitn@iltli2 _--_--- -- I 1 I�spo lion: ffror5 ,�-- C d(rG Au .L.. 119 — fihi%tom m y It@,o9nn@d Ong uv&tably for public vlf3w un the Mrisen County Wobsicv —=� 4A�d 9/12/2017 0 / c