HomeMy WebLinkAboutSWG2018-00412 - SWG Application - 11/13/2018 415 N 6TH STREET,SHELTON,WA 98584
d MASON COUNTY SHELTON:360-427-9670,EXT 400
(1. COMMUNITY SERVICES BELFAIR:360-275-4467,EXT 400
ELMA:360 ,EXT 400
Building,Planntng,Environmental Health,Community Health FAX:369
360-427-7787
On-Site Sewage System Permit: SWG2018-00412
APPLICANT BLACK ET VIR FIONA Phone:
Address: 246 CERRO ST ENCINITAS, CA 92024
OWNER BLACK ET VIR FIONA Phone:
Address: 246 CERRO ST ENCINITAS, CA 92024
SEPTIC DESIGNER TOM WEAVER-Allied Design Inc Phone: 360-830-5308
Address: PO BOX 564 SEABECK, WA 98380
Site Address: E VICTOR RD
Primary Parcel Number: 122214390324
Permit Description: NEW SFR -4BR-Gravity
Permit Submitted Date: 11/13/2018
Permit Issued Date: 07/10/2019
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $590.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 07/10/2023 (based on date of inspection)
Permit Conditions:
1 Permit must be installed by a Mason County Certified Installer unless prior written
authorization from Mason County is obtained.
2 Drain field installation not to exceed designed upslope and downslope depth specified on
design form.
3 Installer is responsible for obtaining Mason County installation approval prior to backfill of
system components.
4 Installer is responsible for obtaining Septic Designer/Engineer installation approval prior to
backfill of system components.
5 Mason County Asbuilt Form, Record Drawing, and Installation fee must be submitted for
final installation approval.
THIS PERMIT MUST BE ONSITE DURING INSTALLATION OF OSS.
PROPERTY OWNERS ARE RESPONSIBLE FOR DETERMINING AND MARKING ALL PROPERTY LINE AND EASEMENT LOCATIONS.
THIS PERMIT MAY BE REVOKED IF THE SITE CONDITIONS HAVE CHANGED SINCE THE SITE WAS INSPECTED AND DESIGN APPROVED.
FINAL INSTALLATION APPROVAL IS REQUIRED PRIOR TO TEMPORARY OR FINAL OCCUPANCY OF ANY RELATED STRUCTURES.
For Final Inspection visit: www.co.mason.wa.us/health/environmental/onsite/oss-inspection-request.php or call:
360-427-9670, extension 400.
`t. MASON COUNTY 415 N 6TH STREET, SHELTON WA 98584
SHELTON: 360-427-9670, EXT.400
o COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
�;, ELMA:360-482-5269, EXT.400
Building,Planning,Environmental Health,Community Health FAX: 360 427 7798
APPLICATION FOR EXTENSION D i- 11 I- -
Amount Paid: (SCE t, ` J U N 3 0 2022
Receipt Number: )-Z-- By
Instructions: Complete Parts 1 and 2. Submit application with extension permit fee. Make check payable to
Mason County Treasurer. Staff will review your application and determine if the extension can be approved. If
approved, the permit may be extended for up to one additional year from the original expiration date.
Extensions must be applied for prior to original expiration date. Multiple extensions on a single permit
will not be approved (one per design/permit).
PART 1: APPLICANT AND PARCEL INFORMATION
Name of Applicant: i)1'+Pt (i__fRC #' Phone: (g.5 s--4-:4,_5 ()5
Mailing Address of Applicant: .fq Cr, C_c 2 Pc) s--1
City: -Cry-(iv (7fik4> State: CA Zip: C'2 J.1 --
12-digit Tax Parcel Number: 1222 1 4R CI40 3 2-6\-
Site Address: I --Cr, E_VICh31- 12 C* e_i CO-X W Ci ,)
Permit Number: SWG -201 gS - 00e-I- 12.
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION.
Purrinci,seck P(hperft 4--(2 3/20 tic-, 1 { p� ��«s
akiref,s 'ftIA 5/2:)/ .. St rice- {{r,(S -kph P, L,)7_ ktue_ n woranci
ciyot-„s <ha_c's, or\ 14\c_:2�22 Pit cs»nt� Or)61�-e It1SITAIAQ ..1, ` �t
-czt�-het t See l.yr-e c-' Cnt Tact c +n`�.l-e t'c_Et�` ric but rife__
aCtl v I L) (Xir=50 t.nc# ran(AL tC o(Dfi F-,n C
PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied
Extension Approved New Expiration Date: 7 )) O /23
Comments:
01%191)V l 1900__d pe,VVn14 paV, SYVtcI eVIA k () -71IropZZ .
Environmental Health Specialist Signature: V\--Nfle4/1(1
r mayscanned and available forpublic view on the Mason CountyWeb site.
This form be
Revised: 12/13/2019