HomeMy WebLinkAboutSWG2020-00259 - SWG Application / Design - 6/12/2020 (2) MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
M .:. BELFAIR:360-275-4467,EXT 400
�-= Public Health & Human Services ELMA:360-482-5269,EXT400
FAX:360-427-7787
On-Site Sewage System Permit: SWG2020-00259
APPLICANT PORTER SCOTT& EVELYN Phone:
Address: P 0 BOX 1923 SHELTON, WA 98584
OWNER PORTER SCOTT & EVELYN Phone:
Address: P 0 BOX 1923 SHELTON, WA 98584
SEPTIC DESIGNER Jim Hunter and Associates Phone: 360-753-1226
Address: PO BOX 162 OLYMPIA, WA 98507
Site Address: E Pickering Rd
Primary Parcel Number: 220215090921
Permit Description: NEW SFR -3BR -Gravity
Permit Submitted Date: 06/12/2020
Permit Issued Date: 07/09/2020
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $625.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 06/23/2024 (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 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: masoncountywa.gov/health/environmental/onsite/oss-inspection-request.php or call:
360-427-9670, extension 400.
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/(OJT MASON COUNTY 415 N 6T"STREET, SHELTON WA 98584
SHELTON: 360-427-9670, EXT.400
l i�' , COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
s rizi ELMA: 360-482-5269, EXT.400
Building Planning,Environmental Health,Community Health FAX: 360-427-7798
APPLICATION FOR EXTENSION r / r ' 11 If \-.1
Amount Paid: * I ,
MAY 0 2 2023
Receipt Number: 1.01''�
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: P?_t l( d(!---f-t\ Phone: Co) 17c- 502 61
Mailing Address of Applicant: PO I1OX 38'-
City: O J< i ((-E State: 0_)4 Zip: 55K
12-digit Tax Parcel Number: 02a2002( -,92 - ?O 9a.
Site Address: Xx P/Ice_rl iij ig4V(. •
Permit Number: SWG c2Wo1.0 — ooaSR
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION.
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PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied
t;iCExtension Approved New Expiration Date: ")--] -2- 1
Comments:
Environmental Health Specialist Signature: ('2 ° " �This form may be scanned and available fo p bL.,
c view on the Mason County Web site.
Revised: 12/13/2019