HomeMy WebLinkAboutSPI N/A - SPI Application - 5/11/2000 'I O d'o 7 MASON COUNTY
SHORELINE PRE-INSPECTION APPLICATION
PLEASE PRINT La�kZ gV l"Ll $70.00 Fee Required
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1. Owner: Applicant:
Site Address: 6W 1 rA,4gq q Q/aeksY4,'yi / - Applicant Address: Pb&r l 2-5--
Owner Add r ss:- 66 1_,5 nE oiZ� !✓r,�°-� City: ✓8
City: c '� St .Zip g ' Phone: �7S--sS9
Phone: ( 1 074/q6i 2. Parcel No. c�c�30 "7� `Inylo
Legal Description: -r? ?A o-4 eSuryW /a�at
3. Purpose of Pre-Ins ectio�n,:: • A�e I-yIke Segsor1/ A),'04
QC�'�C9t Asa ��� Y t o1^e. Qc��/�rDY? TC� Gf�CSl7i'!Oj J7`►'�C7-el r
4. - Use of Building:
5. Is there any type of water on or adjacent to property?: saltwater lake
river pond wetland seasonal runoff other
stream seasonal creek
Directions to Site: Frrm Qeevr e- eek ;ceJO A lurk) ie-( Sri 5��
If the information is incomplete, then Mason County must disclaim any errors resulting from
deficiencies in the original application. Pre-inspection reports remain valid only until
develo ment changes occur in the vicini = hich affect the lot evaluated in this inspection.
Applicant Signature: Date:
Return application to: Department of Community Development,Planning Division
P.O. Box 578
Shelton, WA 98584
(360) 427-9670
Please include a $70.00 check or money order payable to Mason County Treasurer
FOR OFFICE USE ONLY: Accepted by: Date:
Please illustrate below the proposed building site in relation to water & property lines:
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Departmental Review
(For Office Use Only)
Planning Department Findings:
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MASON COUNTY DEPARTMENT OF HEALTH SERVICES
PERM, NO SWG - ( >
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Date
426 W. CEDAR/ P.O. BOX 1666/SHELTON, WA 98584 Cl)
Receip I o.
PHONE (360) 427-9670 Amoun $ `s Z
DATE: 3 CD
OWNER: CHECK APPLICABLE ITEMS `/ m m
MAILING ADDRESS: (, DAYTIME PHONE: NEW SYSTEM X
X 5 �30 we Ala N"�� - I O- - REPAIR SYSTEM 12.
TABLE 6 REPAIR ® v
CITY: (� (� STATE: ZIP:
V� Wq i 9 5 e- MAINTENANCE REVIEW
PROPE TY ADDRESS: SINGLE FAMILY o a
6�d� OTHER: e— Cr
3
SPECIFIC DIRECTIONS FOR LOCATING SITE: PRIVATE WELL m
COMMUNITY WELL/PUBLIC SYSTEM
SYSTEM WFI# n
SYSTEM NAME — Ip
APPLICANT 0, I"
NAME �@
Name of Lot ft.x ft. MAILING ADDRESS
Installer TELEPHONE O Size: acres
Name of Number of SIGNATURE o 1
Designer Bedrooms X ' ,i
OFFICIAL USE ONLY BELOW THIS LINE
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DEPARTMENTAL SOIL LOGS DEPARTMENTAL COMMENTS/CONDITIONS I �
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SOIL TEXTURE CODES:
V=Very G=gravelly S=sand L=loam Si=silt C=clay E=Extremely
INSPECTOR(print name) INSPECTION SIGNATURE DATE PERMIT EXPIRATION DATE
•All systems require ongoing Operation and Maintenance(O&M)as specified in Mason County On-Site Standards.
•All on-site sewage systems must be designed by a Mason County Certified Designer or a Professional Engineer,unless prior approval is granted otherwise
•All on-site sewage systems must be installed by a Mason County Certified Installer,unless prior approval is granted otherwise.In such cases a preliminary on-site
meeting between health department staff and the homeowner is required.
•On-site sewage system design approval does not imply other building site requirements(i.e.RLC,Water Adequacy)have been met.
•Any change from the specified use of the property or any site alteration affecting the system design may invalidate this permit.
•This permit expires 3 years from the date of site review.Denial of this permit maybeaDDealed to the Health Officer within 10 days of denial date.
DESIGN REVIEW APPROVAL BY: DATE: INSTALLATION APPROVED BY: DATE:
TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM: Applicant's Copy
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