HomeMy WebLinkAboutHOMEOWNER INSTALL APPLICATION SWG2023-00520 - SWG Application - 10/25/2024 e ct) kfc,-\--ailvit,, , L/ J�� f4- 6-'4'6-'' t-'6u 4rc/ Uo`.�
r,'- ` 415 N 6TM STREET,SHEL—ON WA 98584
rSHELN 17•`` MASON COUNTY
TON:360-427-9670, EXT.400
s COMMUNITY SERVICES BELFAIR:360-275-4467,EXT.400
__-r- _/ ELMA 360-482-5269,EXT.400
Building.Planning Environmental Health,Community Health FAX 360-427-7798
HOMEOWNER OSS INSTALLATION REQUEST re ,�
Name of Applicant/Owner a d,e �y1�ed1. Date: /0'2�-2� I�-1]
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Mailing Address of Applicant: 7r-J 4V `1 ,�� , e A— N
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City: Q j_/_ ,),C/ti r State:tv - WA kvi,`.Zi N
3400-_s' 4 3- 0 o
Phone Number: Email:,,) .L
12-digit Parcel Number: 1`)-0.-0/g 3DayU °°
Approved Septic Permit Number: 5 ' ' D23 ot3� (see page 1 of design f• m)
Septic Design Expiration Date: / 9 ' I tj ad 2--.(C) (see page 2 of •sign form)
Septic Designer or Engineer: Jim Zimny (see page of design
form)
Designer/Engineer must stamp their approval for homeowner installation
Owner Agreement: I .,: , r,E n mr c St<+rn{?
I am the primary owner of this non-shoreline residential property and
this will be my primary residence. I have read and understand the I v�
attached"Mason County Homeowner OSS Installation Information".". % �t
f �t. • I
1 agree to follow the Mason County procedure,standards, and I
applicable regulations during this installation with the understanding /"P i" '
i thilure to do so may render my design/permit void or unusable.5 �' °��
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Signature of Applicant/0 er
I
HEALTH DEPARTMENT USE ONLY
Request Review: ❑ Approved 0 Denied
INSPECTION DATES:
Name of EH Specialist:
Pre-Install Meeting:
Signature: Date:
D/F Depth Inspection:
Comments: Final Inspection:
This form may be scanned and available for public view on the Mason County Website.
Lpdated 9/12/2017