HomeMy WebLinkAboutSWG2020-00428 - SWG Application / Design - 6/14/2023 584
„ MASON COUNTY 415 N 6TH STREET, 0427-9 7 ,E 98400
SHELTON: 360 427-9670,EXT 400
J L BELFAIR: 360-275-4467,EXT 400
f-�-'- Public Health & Human Services ELMA:360-482-5269,EXT400
FAX:360-427-7787
On-Site Sewage System Permit: SWG2020-00428
0
APPLICANT HOWARTH MATTHEW& JANELL Phone: 1.360.533-0333
Address: P 0 BOX 654 ELMA, WA 98541
APPLICANT TALLEY LANCE B & CATHY J Phone: 360-533-0333
Address: P O BOX 1174 ABERDEEN, WA 98520
OWNER HOWARTH MATTHEW&JANELL Phone: 1.360.533-0333
Address: P 0 BOX 654 ELMA, WA 98541
SEWAGE DESIGNER CHRIS ELSTROTT-Advanced Phone: 360-561-5000
Engineering
Address: 128 NORTH RIVER STREET MONTESANO, WA 98563
Site Address: 18571 W Cloquallum Rd
Primary Parcel Number: 619364100020
Permit Description: NEW SFR - 3BR - Pressure
Permit Submitted Date: 08/26/2020
Permit Issued Date: 09/17/2020
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $850.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 09/17/2024 (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.
�`�j,, r,'/s 415 N 6TH STREET, SHELTON WA 98584
MASON COUNTY SHELTON: 360-427-9670, EXT. 400
COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
ELMA: 360-482-5269, EXT. 400
-: \ Building Planning,Environmental Health,Community Health FAX: 360-427-7798
APPLICATION FOR EXTENSION ri ,., , ,, \),
Amount Paid: A (aD JUL 0 3 2023
Receipt Number: �g
By Instructions: Complete Parts 1 and 2. Submit application with extension permit fee YIE7Fake--check payable to
II 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).
I
PART 1: APPLICANT AND ARCEL INFORMATION
MATION
Name of Applicant: k L{ Phone:(U- 5 0a 57
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Mailing Address of Applicant: _p D -l)x 11 -7!-1 cl
City: t\ Q Y -A-Pfll State: (AA Zip: b �—�
12-digit Tax Parcel Number: b I J(P — — 000 2D Site Address: ( 7/ (//(//1/' V l_o t), [lam d l i/ru_ 4 ` 85
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Permit Number: SWG ,c2() )--0 — 7O ?
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION.
i3 iAy ►n) paptiri" Cl ii d n-ryd /11 06- I/%Yl i &_
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PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied p / ) 7 1... 1..y
Extension Approved New Expiration Date:
Comments:
Environmental Health Specialist Signature: P-1+1, S01 L�
This form may be scanned and available for public view on the Mason County Web site.
Revised: 12'13;2019