HomeMy WebLinkAboutSWG2020-00632 APPLICATION FOR EXTENSION - SWG Application - 11/17/2023 MASON COUNTY 415N6TH STREET,SMELTO",VJA 98584
SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
r Public Health & Human Services ELMA.360-482-526699,4EXT1400
AX. 87
On-Site Sewage System Permit: SWG2020-00632
APPLICANT FIROUZBAKHT ETUX REZA Phone: 425-894-5709
Address: 7977 170th Ave NE REDMOND, WA 98052
OWNER FIROUZBAKHT ETUX REZA Phone: 425-894-5709
Address: 7977 170th Ave NE REDMOND, WA 98052
SEPTIC DESIGNER ROD LEFT-Acme Design Phone: 360-698-8488
Address. PO Box 2954 SILVERDALE, WA 98383
Site Address: 181 NE TIGER WAY EAST
Primary Parcel Number: 123055000025
Permit Description: New three bed-Nuwater trench
Permit Submitted Date: 12/03/2020
Permit Issued Date: 12/23/2020
Issued By: Luke Cencula
Current Permit Fees Paid: $775.00 (additional fees may be required upon iostataton of system).
Permit Expiration Date: 12/2212025 (based on date of inspection)
Permit Conditions:
1 Pump tank(> 1,000 gal capacity) requires two risers to grade per county standards.
2 Proposed development subject to zoning requirements and approval by the planning
department staff per Mason County Title 17.
3 Permit must be installed by a Mason County Certified Installer unless prior written
authorization from Mason County is obtained.
4 Drainfield installation not to exceed designed upslope (14') and downslope (14") depth
specified on design form.
5 Installer is responsible for obtaining Mason County installation approval prior to backfill of
system components.
6 Installer is responsible for obtaining Septic Designer/Engineer installation approval prior to
backfill of system components.
7 Mason County Asbuilt Form, Record Drawing, and Installation fee must be submitted for
final installation approval.
8 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is
obtained
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.
A , MASON COUNTY 415N5„ESTONF6 z;TONWA98584
Public Health & Human Services aELFAIR. 360-275-4467. EXT.400
APPLICATION FOR EXTENSION a.„?
Amount Paid: I Go, — NOV 7 7
2
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Receipt Number: 1S - RFCE/frf0
Instructions: Applicant to complete Parts 1 and 2 and septic designer/engineer to complete
Part 3. 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.
Conditions for approval are outlined in this application.
Prior to or after expiration of an approved design, the applicant may apply for a permit
extension. The permit extension shall extend the expiration of the design for up to two years.,
but not exceed five years from the signature date of the Environmental Health Specialists
site inspection{Per WAC 246-272A-200(4)(e)}
All approved septic designs may receive one extension. Additional extensions shall not be
accepted and would instead require a renewal.
PART 1: APPLICANT AND PARCEL INFORMATION
Name of Applicant RCza rirou.2 AKht ____ Phone: -4as- %14- 5709
Mailing Address of Applicant: 7977 170T Rile NE (Halo
City. R2oLmonol _State: tun Zip: 1105 a.
12-digit Tax Parcel Number: iZtoS- 30 - coo as
Site Address: ht NE Tiy<r Wa-� rest Pair
Permit Number. SWG act() -60631 li H ,
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PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
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This form may be scanned and available for public view on the Mason County Web site.
Page 1 of 2
PART 3: ORIGINAL DESIGNER/ENGINEER REVIEW AND APPROVAL
I. the undersigned original Designer/Engineer, attest that I have reinspected the property and
found the following conditions to be true as of the date of my signature below.
• NO part of the proposed Grainfield or Reserve area has been altered or disturbed in such
a way that may render the proposed design invalid.
• NO development has occurred on this parcel or neighboring parcels which would cause
the proposed system to no longer meet minimum setbacks.
• NO Boundary line adjustments or subdivisions have occurred which would cause the
property to fall below the minimum land area requirements of WAC 246-272A.
Designer/Engineer Stamp:
Noy g .zoz3 • F"
ignature of Designer/Engineer Date
-a ooLR EFT L
. LICENSED =sIorER 171
///71/”i .Iul ,((
EXPIRES 121151 y{
Comments/Conditions:
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1 I6 1207-3 _ -- —
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied 7 /
ti Extension Approved New Expiration Date: 2/ L 7 C ZCzs
Comments
Environmental H1alist Signature
This form may be scanned and available for public view on fli4',Masgn.,Cp,unty Web site.
s'age 2 of 2