HomeMy WebLinkAboutSWG2020-00085 APPLICATION FOR EXTENSION - SWG Application - 4/15/2020 •
MASON COUNTY 415 N 6TH STREET, SHELTON WA 98584
SHELTON: 360-427-9670, EXT. 400
'I I' i COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
-, --- „ ELMA: 360-482-5269, EXT.400
Building,Plenning.Environmental Health,Community Health FAX: 360-427-7798
APPLICATION FOR EXTENSION
Amount Paid: -
-
Receipt Number:
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: d-� 1 01 € LU Phone:(SO 1) 4495
Mailing Address of Applicant: 9 lP O P W A`(
City: l---a G e State: \X) 1 Zip:9 g S UJ
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12-digit Tax Parcel Number: 3 2a 2 l -- le
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Site Address: J l I g Sod �Y ) 3\1'e (4-c�v�� L A 1 g 5 8 4
Permit Number: SWG Zo20- DOo
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION. .1
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PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied Extension Approved New Expiration Date: 1-5I ZL-,I I
Comments:
Environmental Health Specialist Signature:
This form may be scanned and available for public view on the Mason County Web site.
Revised: 12/13/2019
MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON: 360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
P Public Health & Human Services ELMA:360482-5269,EXT400
<A FAX:360-427-7787
On-Site Sewage System Permit: SWG2020-00085
APPLICANT BOILEAU WILLIAM D Phone: 509-981-4495
Address: 9608 6TH WAY LACEY, WA 98503
OWNER BOILEAU WILLIAM D Phone: 509-981-4495
Address: 9608 6TH WAY LACEY, WA 98503
II
SEPTIC DESIGNER PAULA JOHNSON -Arrow Septic Phone: 360-898-2255
Designs Inc.
Address: 171 E VUECREST DRIVE UNION, WA 98592
Site Address: 311 E SOUNDVIEW DR
Primary Parcel Number: 320215902018
Permit Description: New two bed SFR- Nuwater trench
Permit Submitted Date: 03/06/2020
Permit Issued Date: 04/15/2020
Issued By: Luke Cencula
Current Permit Fees Paid: $615.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 04/13/2024 (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 Drainfield 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: masoncountywa.gov/health/environmental/onsiteloss-inspection-request.php or call:
360-427-9670, extension 400.