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HomeMy WebLinkAboutSWG2021-00200 APPLICATION FOR EXTENSION - SWG Application - 4/15/2024 40 MASON COUNTY 415 N C'STREET,SHELTON WA 96584 SHELTON:360427-9670,EXT.400 Public Health & Human Services BELFAIR:360-2754467,EXT.400 APPLICATION FOR EXTENSION Amount Paid: � 166 _ APR 15 2 0 1� Receipt Number. aoa4- o1+312 Re , 0 Instructions: Applicant to complete Parts 1 and 2 and septic designer/engineer to comple 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 Specialist's 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 I nn Name of Applicant: t;nntfer (� OACMOY� Phone: 5yj - 0 dGi1nn o -nZ!�-C) Mailing Address of Applicant: 1 R 5q 66f ien t O. D 12 s City: TIAmkater State: ww Zip: q T / Z 12-digit Tax Parcel Number: e/z 002g - '7 e - 7c o 7 u c Site Address: 9 0 L9 . V` eC, 0 e)"--, 5 7t j{ w Permit Number: SWG ZA ZZ - oo ZO© 9�SSy PART 2: EXPLAIN WHY YOU NEED AN EXTENSION -fhe -S4arf- o[ PrmslruC-hM has been d p W ed bu Hance s This form may be scanned and available for public view on the Mason County Web site. Page 1 of 2 a< Paccol �:P- , Y2 B --M' - 9007 V 1 hancellirr PART 3: ORIGINAL DESIGNER/ENGINEER REVIEW AND APPROVAL I, the undersigned original Designer/Engineer, attest that 1 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. fDesi Ole P. OF Signature of Designer/Engineer Date I Comments/Conditions: — — — — — — PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only) ❑ Extension Denied 7 7 Extension Approved New Expiration Date: Comments: Environm I Health Specialist Signature: APR 15 ?c,. is form may be scanned and available for public view on the Mason County Web site. aaoo 2 of