HomeMy WebLinkAboutSWG2021-00316 - SWG Application / Design - 6/1/2021 (2) MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
mat Public Health & Human Services ELMA: 360 482-5269,EXT 400
FAX:360-427-7787
On-Site Sewage System Permit: SWG2021-00316
APPLICANT Steven Rodacker Phone: 253-232-9990
Address: 8511 Shawnee PL NW GIG HARBOR, WA 98335
OWNER WHITEHOUSE STEPHEN T Phone:
Address: 1670 E ISLAND LAKE DR SHELTON, WA 98584
SEPTIC DESIGNER JUSTIN RUSSELL-JIM HENRY SEPTIC Phone: 360-956-7242
DESIGN LLC
Address: PO BOX 14531 TUMWATER, WA 98511
4
Site Address: E Leeds Dr
Primary Parcel Number: 320222490010
Permit Description: New 4 bd pressure trench
Permit Submitted Date: 06/01/2021
Permit Issued Date: 06/21/2021
Issued By: Rhonda Thompson
Current Permit Fees Paid: $635.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 06/17/2025 (based on date of inspection)
Permit Conditions:
1 Proposed development subject to zoning requirements and approval by the planning
department staff per Mason County Title 17.
2 Permit must be installed by a Mason County Certified Installer unless prior written
authorization from Mason County is obtained.
3 Drain field installation not to exceed designed upslope and downslope depth specified on
design form.
4 Installer is responsible for obtaining Mason County installation approval prior to backfill of
system components.
5 Installer is responsible for obtaining Septic Designer/Engineer installation approval prior to
backfill of system components.
6 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.
.
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0MASON COUNTY 415 N 6T"STREET, SHELTON WA 98584
SHELTON:360-427-9670, EXT.400
COMMUNITY SERVICES BE FAIR: 360-272 4426?,EXT.400
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Building,Planning.Environmental Health,Community Health FAX: ;'. e,',7798
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APPLICATION FOR EXTENSION / �'
Amount Paid: l �U •.• s,9 a
Receipt Number:pal c�- O ao •..
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: \Z\e Qc .c.`Kiv '"N-N0CC YD'-')(k- Phone: ZS3 "2 -1- - 590
Mailing Address of Applicant: ' S\\ .S )c wr1ee PL I\)vJ
City: t5 k\cAo State: W Zip: 35
12-digit Tax Parcel Number: 3 Q 0 ' a - . 9 - q a T ( 0
Site Address: b)(0 L Le eS ('\2 ,\ , Wilc 9(6' \
Permit Number: SWG 10L\ Ub1i(
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION.
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PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied11() -----
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Extension Approved New Expiration Date: / 1 f 2 --)
omments:
.41-1\-QX\A(1
Environmental Health Specialist Signature:
This form may be scanned and available for public view on the Mason County Web site.
Revised: 12/13/2019