HomeMy WebLinkAboutSWG2020-00240 APPLICATION FOR EXTENSION - SWG Application - 2/12/2024 J ,
MASON COUNTY 415 NSHELTON:360-427-9670.EXT 400
Public Health & Human Services BELFAIR 360-275-4467,EXT.400
APPLICATION FOR EXTENSION
Amount Paid: ( (05• —
Receipt Number:
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: K%She�ke CCJ-ec, Phone: (25�223- b"19¢
Mailing TAddress of Applicant: 3503 ZZND �S+ SW
City: l 1\ unklu,o State: \[Jf� zip: q83�
12-digit Taxumber. 2 — 7 S 000 ii Q
Site Address: Tee L0.k e 9C Ta.h � Wl'!k ges BS
Permit Number: SWG 2020- 0t77'pD
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.
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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 WAC 246-272A.
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Signature of Designer/Engineer Date IpAUTA Joy aJOHN'ON
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Comments/Conditions: — — — — — — — —
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied
rCExtension Approved New Expiration Date:
omments:
Environmental HealthSpecialist Signature:
1 " ('- �
This form may be scanned and available for public view on the Mason County Web site.
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