HomeMy WebLinkAboutSWG2020-00400 APPLICATION FOR EXTENSION - SWG Application - 8/22/2023 MASON COUNTY
6'"STREET, SHELTON WA 98584
Cll.- ON:360-427-9670, EXT. 400
COMMUNITY SERVICESLFA -• 360-275-4467, EXT.400
A�...-�"`"' ,. AUGp 2 ELM : 360-482-5269, EXT.400
ji Building,Planning Environmental Health Community Health 4 Z0?3 FAX:360-427-7798
APPLICATION FOR EXTENSI •
Amount Paid: L64 r �' a 1 UZ3
Receipt Number:
_ _ 1
Instructions: Complete Parts 1 and 2. Submit application r+ h 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-}/tea Cordell ti Buti (Lit Lk. Phone: $13" 91010 - 3 ) 31
Addfess cji J22►2 Da wn V s-I- , DI(City: RtVeirv►eVJ State: F L Zip: 33 57 2
12-digit Tax Parcel Number: 9 22 05 - S t - 010 63
Site A,d&ess: Z l N Pl s�ar-�', /Pt cl 2542 ---
Permit Number SWG 2020- 00400
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION.
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PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only)
0 Extension Denied /� P p R®Ar �/Extension Approved /`1 rationDate: t/ZG/7o Z L/
Co►n ts: AUG 2 8 2023
MASON COUNTyENVIRONMENTAL H-
Environmental Health Specialist Sigr{afgre:
This form may be scanned and available for public view on the Mason County Web site.
MASON COUNTY 415 N 6TH STREET,TEL
WA 98584
SHELTON: 42 T 967 400
,EXT
�(�l� BELFAIR:360-275-4467,EXT 400
�� �� Public Health & Human Services ELMA: 360-482-5269,EXT 400
FAX:360-427-7787
On-Site Sewage System Permit: SWG2020-00400
APPLICANT BULLUCK TYRA CORDELIA Phone:
Address: 12212 DAWN VISTA DR RIVERVIEW, FL 33578
OWNER BULLUCK TYRA CORDELIA Phone:
Address: 12212 DAWN VISTA DR RIVERVIEW, FL 33578
SEPTIC DESIGNER ANTHONY DEMIERO Phone: 360-877-5200
Address: PO BOX 1174 HOODSPORT, WA 98548
Site Address: 21 N Ruddy PI
Primary Parcel Number: 422055101068
Permit Description: NEW SFR -2BR - Pressure
Permit Submitted Date: 08/14/2020
Permit Issued Date: 09/01/2020
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $850.00 (additional fees may be requ red upon installation of system).
Permit Expiration Date: 08/20/2024 (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/healthlenvironmental/onsiteloss-inspection-request.php or call:
360-427-9670, extension 400.