HomeMy WebLinkAboutSWG2019-00398 APPLICATION FOR EXTENSION - SWG Application - 8/15/2022 MASON COUNTY 415N H STREET, 042E-96ICE 98584
BHELTRE T, SHE TON A 98584
COMMUNITY SERVICES BELFAIR:360-275-4467, EXT,400
ELMA:360482-5269,EXT.400
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APPLICATION FOR EXTENSION
Amount Paid: filSd'
Receipt Number: 1Z — q'L I CI
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 designipermit).
PART 1: APPLICANT AND PARCEL INFORMATION
Name of Applicant: Agnp11_Li 1, L(oF 6 /_(- Phone:
Mailing Address of Applicant:1- q 7 4 S 37`2=, A 4T
City: A 0 go k 4 state: LO A zip: 4-
12-digit Tax Parcel Number: 3 220 2 _ <�O — (-)O45/
Site Address: ,'' N)F Nne7n+ SA0 9 —
Permit Number: SWG am -- 2011
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION.
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PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only)
0 Extension Denied
.LT txtension Approved New Expiration Date: _t1>�
Comments:
Environmental Health Specialist Signature:
This form may be scanned and availa ubfic view on the Mason County web site.
Revised: 12/13/2019
415 N 6TH STREET,SHELTON,WA 985M
MASON COUNTY SHELTON'360427-9670.EXT 400
0 COMMUNITY SERVICES BELFAIR:380-275-"67,EXT 40D
ELMA:360<82-5269.EXT 400
s,iyngeLvny.enr:mm.na x��cemn,.anw.im FAX:360427-7787
On-Site Sewage System Permit: SWG2019-00398
APPLICANT GRANT D 8 CANARA CALLIN Phone:
Address: 21631 NE 24TH ST SAMMAMISH,WA 98074-6339
OWNER GRANT D&CANARA CALLIN Phone:
Address: 21631 NE 24TH ST SAMMAMISH,WA 98074-6339
SEPTIC DESIGNER MICHAEL STATEN Phone: 360-275-9374
Address: PO BOX 984 BELFAIR,WA 98528
Site Address: 20613 NE NORTH SHORE RD
Primary Parcel Number: 322075000923
Permit Description: Renewal of SWG2015-00318
Permit Submitted Date: 10/09/2019
Permit Issued Date: 11/18/2019
Issued By: Rhonda Elliott
Current Permit Fees Paid: $605.00 (additional fees may oa required soon Installation of system).
Permit Expiration Date: 11/1812023 (bases on data of msaed-on)
Permlt Conditions:
1 Permit must be installed by a Masan County Certified Installer unless prior written
authorization from Mason County is obtained.
2 Dreinfield 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.usiheakWonvlronmentallonsiteloss-inspeclionrequest.php or call:
360-427-9670,extension 400.