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Home My WebLink AboutSWG2021-00046 - SWG Application / Design - 1/28/2021 (2) MASON COUNTY 415N BTHELTON: 60427-9670, 98884 $HELTOR:360d27-9810,EXT 400 4 BELFAIR:380-275-0487,EXT 400 Public Health & Human Services EWA:380-4825269,EXT 400 FAX:380427-Tr87 On-Site Sewage System Permit: SWG2021-00046 APPLICANT MORIE L CHURCHMAN PHINNEY Phone: 1.360.271 A294 Address: 5756 Eldorado PI NW BREMERTON,WA 98312 OWNER MORIE L CHURCHMAN PHINNEY Phone: 1.360.271.4294 Address: 5756 Eldorado PI NW BREMERTON,WA 98312 SEPTIC DESIGNER PAULA JOHNSONe Phone: 360-898-2255 Address: 171 E VUECREST DRIVE UNION,WA 98592 Site Address: 132 NE Tiger Lake Rd W Primary Parcel Number: 123052100101 Permit Description: New three bdrm-pressure trench Permit Submitted Date: 01/28/2021 Permit Issued Date: 02/08/2021 Issued By: Luke Cencula Current Permit Fees Paid: $640.00 (adLNonal leas my ne wutm won muiia"°n°rsvmm). Permit Expiration Date: 02/04/2026 (eased on dso of nspx on) 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 downslupe depth specked 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 DesignerlEngineer 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. 7 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is obtained 9 Installer responsible forproper tightline installation per design. 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/environmentallonsiteloss-inspection-request.php or call: 360-427-9670, extension 400. 6TH STREET,SHELTON WA MASON COUNTY 45NSHELTON:360-427960 EXT98400 BELFAIR:360-275-4467,EXT.400 Public Health & Human Services APPLICATION FOR EXTENSION L M42 0�014 Amount Paid:� l6 -a RECEIVED 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 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 Name of Applicant: k-9rj rte CT��'�'n �_ Phone: 3(0() Mailing Address of Applicant 5 1 S(o �k axu'�q�"a-J` Jam' q City: State: I zip: 1 31 Z 12-digit Tax Parcel Number: IZ-?JOS— Z� - ()O (n \ Site Address: ) NET L'-�' LAO III��111s�f�6pp��r`g55��4��rf �CC11 Permit Number: SWG I,,/;; 11 2 ti L��l1l�l PART 2: EXPLAIN WHY YOU NEED AN EXTENSION IsY-------------- 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 1, 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. oi..agooi i St"o:� Signature of Designer/Engineer Date PAULA JOY JOHNS ON ( �7b7w� I Comments/Conditions: PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only) ❑ Extension Denied / /GlO�� Extension Approved New Expiration Date: Comments.Enviro en I Health Specialist Signature: PP' `R OVEO / MAY 10 2024 is form may be scanned and available for publAI 4W'dq," O n county Web site. NMENTAL NEALTP OJA Page 2 of 2