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HomeMy WebLinkAboutSWG2020-00304 - SWG Application / Design - 7/2/2020 (2) 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: SWG2020-00304 APPLICANT SIMPSON STUART B Phone: 360-271-9107 Address: 13405 138TH AVE KPN GIG HARBOR, WA 98329 OWNER SIMPSON STUART B Phone: 360-271-9107 Address: 13405 138TH AVE KPN GIG HARBOR, WA 98329 SEPTIC DESIGNER PAULA JOHNSON -Arrow Septic Phone: 360-898-2255 Designs Inc. Address: 171 E VUECREST DRIVE UNION, WA 98592 Site Address: UNKNOWN Primary Parcel Number: 320215601038 Permit Description: New three bed SFR- Nuwater trench Permit Submitted Date: 07/02/2020 Permit Issued Date: 07/21/2020 Issued By: Luke Cencula Current Permit Fees Paid: $625.00 (additional fees may be required upon installation of system). Permit Expiration Date: 07/17/2024 (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/onsiteloss-inspection-request.php or call: 360-427-9670, extension 400. l� ft 11 cm",". 'IMASON COUNTY415 N 6TH STREET, SHELTON WA 98584 I SHELTON: 360-427-9670, EXT. 400 COMMUNITY SERVICESBELFAIR: 360 275 4467, EXT. 400 ELMA: 360-482-5269, EXT.400 Building,Planning,Environmental Health,Community Health FAX 360-427-7798 C C DQ APPLICATION FOR EXTENSION Amount Paid: l'1 0 Receipt Number: 2.0 -Oz1c —( 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:c S (-,'7V? )- O. c5t r'1 /15,0"1/ Phone: o2 5, 453 --ai .S Mailing Address of Applicant: /.3 yd 5 /.__ &LI' 4ve- • Al,ais / City: Gbh )9,94 State: e..2)1. Zip: J� ,> 12-digit Tax Parcel Number: 3 ozb Z- l - 5-4 - zD/ ? 3 8 Site Address: 5 / / • 64 a� L e /2 L . Permit Number: SWG -9 2v — 6 b d L-1, PART 2: EXPLAIN WHY YOU NEED AN EXTENSION. I. 7L(, ,,1-- it'd nv GcJ i f A ('d/✓ �/�A-c' 6o ,2 © .rt/ PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only) 0 Extension Denied �/Extension Approved New Expiration Date: l / 17 tz-"i It Extension Environmental Health Specialist Signature: W ( f 7i /----S This form may be scanned and available for public view on the Mason County Web site. Revised: 12/13/2019