HomeMy WebLinkAboutSWG2021-00657 HOMEOWNER INSTALL - SWG Application - 2/13/2024 qd-14, 1-qh,
MASON COUNTY • - -tool 6'STREET.SHELTON WA 98584
COMMUNITY SERVICESSHELTON: 360.427.8670, EXT.400
' BEI AIR: 360-275-4467, EXT.400
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- —EWA 360.482-5269, EXT.400
,'"e'"� FAX 360-427-7798
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HOMEOWNER OSS INSTALLATION REQUEST
Name of Applicant/Oss ner: jC3,Vfl �s�•;e.txtsul Date: /3 .
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Mailing Address of:Applicant: k C(c r--)r,4t,., � j-r,
City: 7 c- * / (
~��� State: `\ Lip: )136-
Phone Number:(L-- 2A6--449)J - Email: (s\W" t ti -C'4 t t1.
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I 2-digit Parcel Number: 3.2. Z I L 1(QC)(.. C )O
Approved Septic Permit Number: SWG 2-C,2 --EC45��
� (see page l of desiRrt.form/
Septic Design Expiration Date: -_ (sec page 2U/derign•/i)rm) '
Septic Designer or Engineer: 1"\..L \.i i] `�y\ -- (seepage l q/clesig►r Meat)
Designer/Engineer must.stamp their approval for homeowner installation.
Owner Agreement: "- j
/unr the primary owner of this non-shoreline rec identical property and q
this will he nn•prinum•residence. I have read and understand the ) e1 •�0Y �0
� WAS~attached"Mason County Homeowner OSS Installation Information". <J l4OF t%\
l agree to follow the Mason County procechu•e, standards. and i Y r- r
applicable regulations during this installation„Ohthe raukrstcauling r I . `• - .
that fallow to do so may render nn'design.'permit raid or unusable. f r J
. •F45 • • 44
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Signature oofApplicanOwner ,� ,�, ,-_ .._.• - _.... _ •,,,,
HEALTH DEPARTMENT LSE ONLY
Request Review: 'Approved ❑ Denied ....__._. ...,. ...__.._.._
Name of EH Specialist: I INSPECTION DATES:11 `'� „)
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Pre Install Meetrn �l
_____S5LL
Signature: �/ Y Hate:
e 11�c
T 0/F Depth Inspection: 3^ `�^q l
Comments: 1 '?? ,`Y/'
Finallrsoection: �Ji I
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Mason County Homeowner OSS Installation Information
This form may be scanned and available for public view on the Mason County Webs4e.
Updated 2/11/2021