HomeMy WebLinkAboutAPPLICATION FOR EXTENSION SWG2020-00322 - SWG Application - 6/2/2023 MASON COUNTY 415 N 6TH STREET, SHELTON WA 98584
z SHELTON: 360-427-9670, EXT.400
..) COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
—` ELMA:360-482-5269, EXT. 400 1
Building,Planning,Environmental Health,Community Health FAX: 360-427-7798
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APPLICATION FOR EXTENSION 0 IE [ u w' -
Lea Amount Paid: ' ^. ` APR Ol 2023
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JUN 0 2 2023 -
Receipt Number: �3 0
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RECEIVED
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: ,_:,-1,(ry re v bt,CLe-VW(I i Phone: 3(4 0 4-6lO I 2O(Q
Mailing Address of Applicant: ¢7(QO Ct) tSket j�ovwc t tL _ f i2 l/
City: �?it e-( \- State: 1A11l Zip: 9 e s6 4-
12-digit Tax Parcel Number: 4- 2 j 1 S" -7 S "` '1O I 0-0
Site Address: ': L: ( E &iivt Z ` C 12-61
Permit Number: SWG 202_0 - 00 ZZ
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION.
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PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied / 15/Extension Approved New Expiration Date: ( ZO U
Comments: APPROVED
Environmental Health Specialist Signature: JUN 0 2 2023
This form may be scanned and available for public view on the 114aiiI&Qtl ii'ii Alit tiAL HEALTH
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Revised: 12/13/2019
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MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670, EXT 400
BELFAIR:360-275-4467, EXT 400
,'[ Public Health & Human Services ELMA:360-482-5269, EXT400
FAX:360-427-7787
On-Site Sewage System Permit: SWG2020-00322
APPLICANT UNDERWOOD LAURREN & CLAY Phone: 808-253-9346
Address: 4760 W Skokomish Valley Rd SHELTON, WA 98584
OWNER UNDERWOOD LAURREN & CLAY Phone: 808-253-9346
Address: 4760 W Skokomish Valley Rd SHELTON, WA 98584
SEPTIC DESIGNER Jim Hunter and Associates Phone: 360-753-1226
Address: PO Box 162 OLYMPIA, WA 98507
Site Address: 361 E Sunset Ridge Rd
Primary Parcel Number: 421137590100
Permit Description: New three bed SFR- pressure trench
Permit Submitted Date: 07/09/2020
Permit Issued Date: 07/20/2020
Issued By: Luke Cencula
Current Permit Fees Paid: $625.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 07/15/2024 (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 (9') and downslope (8') 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.
6 Gravelless chambers are required in drainfield.
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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