HomeMy WebLinkAboutSWG2021-00198 - SWG Application / Design - 4/15/2021 MASON COUNTY 475N 6SHELTON:STREET,SHELTO70,EXT 684
SHELTON:360-2754 7,EXT 400
Public Health & Human Services aE EWA 360.2]544fi7,EXT 100
ELMA:360i82-5289,EXT 400
4 FAX 360427-7787
On-Site Sewage System Permit: SWG2021-00198
APPLICANT NAHOKO UEDA Phone: 1.206.992.7474
Address: 4022 Stone Way N SEATTLE,WA 98103
SEPTIC DESIGNER PAULAJOHNSON• Phone: 360-898-2255
Address: 171 E VUECREST DRIVE UNION,WA 98592
Site Address: 130 Evergreen Rd
Primary Parcel Number. 122065100009
Permit Description: New 2bd Nuwater to Oscar
Permit Submitted Date: 04/15/2021
Permit Issued Date: 04/30/2021
Issued By: Rhonda Thompson
Current Permit Fees Paid: $640.00 la&Wonal rasa mar ua,aam,ad uoon dmwauon w:nraml.
Permit Expiration Date: 04/2912026 (6a oadamormw+)
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 Dreinfield installation not to exceed designed upslope and downslope depth specttled 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 Asbuift 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/health/environmentallonsite/oss-inspection-request.php or call:
360-427-9670,extension 400.
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MASON COUNTY 415N6T"STREET,SHELTON WA 98584
SHELTON:360-427-9670,EXT.400
r, BELFAIR:360-275446Z EXT.400
Public Health & Human Services
APPLICATION FOR EXTENSION
Amount Paid: K 0 -S
Receipt Number:A4 . 13 ;Qc`,%S 6
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 Specialist's
site inspection{Per WAC 246-272A-200(4)(e))
All approved septic designs may receive one extension. Additional extensions shall n be
accepted and would instead require a renewal.
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PART 1: APPLICANT AND PARCEL INFORMATION RF 2 �Z�26
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Name of Applicant: Nahoko Ueda, Ueda Design Studio Phone: 206.992.7474
Mailing Address of Applicant: 4022 Stone Way N, Unit 100
City: Seattle State: WA Zip: 98103
12-digit Tax Parcel Number:122065100008 and 122065100009(the lots have been combined under 12206510008
Site Address: 110 and 130 E Evergreen Road, Belfair, WA 98528
Permit Number: SWG 2021-00198 "I' 5�1757fl
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PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
It took a while for us to find a GC who can take this project because of the steep slope site.
We finally found a GC and are about to start the construction. However, we need a bit more
time to start/ complete the septic system installation.
This form may be scanned and available for public view on the Mason County Web site.
Page.1 &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 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 24&272A.
IDesfgnec` I
Signature of Designer/Engineer Date I PAULAJ9VJJOeN50N�.�F�
610,
Comments/Conditions: — — — — — — — —
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied X
Extension Approved New Expiration Date: _ /L/ /l Z
mments:
Environ entaI Health Specialist Signature:
MAY 202014
bASouew ENV!P N9)irQ�GWPWeb site.
This form may pu on be scanned and available for blic view on tl� a
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