HomeMy WebLinkAboutSWG2020-00431 APPLICATION FOR EXTENSION - SWG As-Built - 8/24/2023 MASON COUNTY 1401/ 6TH STREET, SHELTON WA 98584
■'' '' COMMUNITY SERV CE&UG 2 4 SHELTON:AIR: 360-275-4467, EXT. 400
BELFAIR: 360 275 4467, EXT. 400
2��3 ELMA: 360-482-5269, EXT. 400
Building,Planning,Environmental Health,Community He RECEIVED
360-427-7798
ECEIVED
APPLICATION FOR EXTENSION ( T O s O `'J r
Amount Paid: l6 6 AUG 212023 L
Receipt Number:
By 410
Instructions: Complete Parts 1 and 2. Submit application with extension permit fee. raa e c ec pays le 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 f
Name of Applicant: S+e p k ey Ae-1 ►�v 1 a 5 Phone: "T 2 S- Z&O --OO 1 9
Mailing Address of Applicant: IOZ 3 v} l
ICity: 5I•\-e401 State: OA Zip: 7 ES-ThH` 9f
42-) 2- 6.77100Z1
12-digit Tax Parcel Number: ,
Site Address: Le,/ ' h1 rr - //�
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Permit Number: SWG 202o - OO J 3 1
I
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION.
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PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied APn� f///2o
QeV 2 L/
[Extension Approved ►I,Don Date:
Comments: AUG 2 8 2023
MASON cot/
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Environmental Health Specialist Signa : A/jH
This form may be scanned and available for public view on the Mason County Web site.
Revised: 12/13/2019
MASON COUNTY 415 N 6TH STREET,SHELTON, , E 98584
SHELTON: ,SHE TON, , EXT 400
584
BELFAIR:360-275-4467,EXT 400
raj
Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
On-Site Sewage System Permit: SWG2020-00431
APPLICANT REYNOLDS STEPHEN JAMES &
TIFANIE BROOKE Phone:
Address: 1028 BAYVIEW AVE SHELTON, WA 98584
OWNER REYNOLDS STEPHEN JAMES &
TIFANIE BROOKE Phone:
Address: 1028 BAYVIEW AVE SHELTON, WA 98584
SEPTIC DESIGNER DALE TAHJA- Septic Designer Phone: 360-426-5940
Address: 2450 W DEEGAN ROAD WEST SHELTON, WA 98584
Site Address: XXX E Lexington PI
Primary Parcel Number: 421257790021
Permit Description: New four bed SFR- pressure trench
Permit Submitted Date: 08/27/2020
Permit Issued Date: 07/21/2022
Issued By: Luke Cencula
Current Permit Fees Paid: $1,000.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 09/09/2024 (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/environmental/onsiteloss-inspection-request.php or call:
360-427-9670, extension 400.