HomeMy WebLinkAboutAPPLICATION FOR EXTENSION SWG2020-00243 - SWG Application - 5/31/2023 MASON COUNTY 415 N 6TH STREET, SHELTON WA 98584
SHELTON: 360-427-9670, EXT.400
// ELMA: 360-482-5269, EXT. 400
COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT. 400
/ Building,Planning,Environmental Health,Community Health FAX: 360-427-7798
[21ril APPLICATION FOR EXTENSION RECEIVED
JUN 0 2 2023 Amount Paid: 1 '0 • ' MAY 3 1 2023
Receipt Number: 13 • ZSC 1 615 W. Alde
r er Street
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: GRESSETT, RICHARD R & AUTUMN C Phone: 253-882-8982
Mailing Address of Applicant: 4423 68TH AVE WEST
UNIVERSITY PLACE WA 98466
City: State: Zip:
12-digit Tax Parcel Number: 22224-75-90060
Site Address: E COON DR N
Permit Number: SWG 2020-00243
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION.
We encountered delays in the construction process due to unforeseen circumstances relating
to the installation of our well, we are requesting an extension to ensure compliance
with all necessary regulations
PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only) APR 01 2023 i
❑ Extension Denied
'd6105(� L By _ -s_.
Extension A roved New Expiration Date: -
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Comments: O VE D
PR
- JUN 0 2 2023
Environmental Health Specialist Signature:
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This form may be scanned and available for public view on the Mason county pJA FAL HEALTH
Revised: 12/13/2019
nvri A
MASON COUNTY 415 N 6TH STREET,6SHELT967 ,E 98400
SHE TREE ,S 42 TON, ,EXT 400
584
BELFAIR:360-275-4467,EXT 400
r Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
On-Site Sewage System Permit: SWG2020-00243
APPLICANT GRESSETT RICHARD R &AUTUMN C Phone: 1.253.228.0456
Address: 4423 68TH AVE WEST UNIVERSITY PLACE, WA 98466
OWNER GRESSETT RICHARD R & AUTUMN C Phone: 1.253.228.0456
Address: 4423 68TH AVE WEST UNIVERSITY PLACE, WA 98466
SEPTIC DESIGNER PAULA JOHNSON -Arrow Septic Phone: 360-898-2255
Designs Inc.
Address: 171 E VUECREST DRIVE UNION, WA 98592
SEPTIC INSTALLER ARROW EXCAVATING Phone: 360.898.4388
Address: PO BOX 94 UNION, WA 98592
Site Address: E Coon Dr N
Primary Parcel Number: 222247590060
Permit Description: NEW SFR -4BR - Pressure
Permit Submitted Date: 06/08/2020
Permit Issued Date: 07/14/2020
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $625.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 06/08/2024 (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/environmentallonsiteloss-inspection-request.php or call:
360-427-9670, extension 400.