HomeMy WebLinkAboutSWG2021-00074 - SWG Application / Design - 2/8/2021 (2) 584
MASON COUNTY I15NBT4ELTON STREET,SHELTON,
-967 ,EXT 400
SHELTON:360d27-9870,EXT 400
i# BELFAIR:360-2754 7,EXT 400
Public Health & Human Services ELMA:360482-5269,EXT 400
FAX:360427-7787
On-Site Sewage System Permit: SWG2021-00074
APPLICANT TWYMAN BYRON & KERI Phone: 503-267-6008
Address: 1246 SE HENRY ST PORTLAND, OR 97202
OWNER TWYMAN BYRON& KERI Phone: 503-267-6008
Address: 1246 SE HENRY ST PORTLAND, OR 97202
SEPTIC INSTALLER JAMIE WORKMAN' Phone: 360-463-9573
Address: 120 E TIMBERLAKE DR SHELTON,WA 98584
SEWAGE DESIGNER MICAH HALVERSOW Phone: 360490-6365
Address: PO BOX 1519 SHELTON,WA 98584
Site Address: 761 N Duckabush Or N
Primary Parcel Number: 422055101017
Pennit Description: New SFR -4BR Pressure
Permit Submitted Date: 02/08/2021
Permit Issued Date: 02/16/2021
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $640.00 (additional ees may be Komi opan installation of system}
Permit Expiration Date: 02116/2026 (based on data of nspeettonl
Permit Conditions:
1 Proposed development subject to zoning requirements and approval by the planning
department staff per Mason County Title 17.
2 Permit must be installed by a Mason County Certified Installer unless prior written
authorization from Mason County is obtained.
3 Drainfield installation not to exceed designed upslope and downslope depth specified on
design form.
4 Installer is responsible for obtaining Mason County installation approval prior to backfill of
system components.
5 Installer is responsible for obtaining Septic Designer/Engineer installation approval prior to
backfill of system components.
6 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.govlhealthlenvironmentallonsiteloss-inspection-request.php or call:
360427.9670, extension 400.
40 MASONCOUNTY 415 N 6TM STREET,SHELTON WA 98684
SHELTON:360-427-9670, EXT 400
Public Health & Human Services BELFAIR:360-275-4467,EXT.400
APPLICATION FOR EXTENSION AO -
s^
Amount Paid: _I.5_
Receipt Number: 1P)LI,
Instructions: Applicant to complete Parts land 2 and septic designer/engineer t mpl
Part 3. Submit application with extension permit fee. Make check payable to Mason ounty a
Treasurer. Staff will review your application and determine if the extension can be ap v
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 y rs,
but not exceed five years from the signature date of the Environmental Health Special) 's
site inspection(Per WAC 246-272A-200(4)(e))
All approved septic designs may receive one extension. Additional extensions shall no r� 624
accepted and would instead require a renewal.
PART 1: APPLICANT AND PARCEL INFORMATION
Name of Applicant: g urev1 T41\�04A V\ Phone: 30 3 - 2 r.-f p�
Mailing Address of Applicant: (2 Nh PrKe /9 t
City: State: Or. Zip: 47 ?1)Z
12-digit Tax Parcel Number: 1t2 205 ^ 51 _ 01 O (7
Site Address: -76I /U Du�knhlch �J• doodsporl I`.` A
Permit Number: SWG 2021- IOd7N
APART 2: EXPLAIN WHY YOU NEED AN `EXTENSION 1 l 1
1Awkr44k 0a s. tint WSrC- afllylr cx(JifC� Ub`� la t`�- 4C�it'ow� ' ��'�'1�
This form may be scanned and available for public view on the Mason County Web site.
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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 Drainfield 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 WAG 246-272A.
Designer/En lneer Stamp:
I I
Signature of Designer/Engineer Date
sn"M
Isxd I
Comments/Conditions: — — — — — — — —
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied
L�Extension Approved New Expiration Date:
/comments:
APPK(N
Enviro mental Health Specialist Signature: ED
MAR 2 7 2024
This form ublic view Mon the ASCIN Masoib§6W*4b%ft-
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