HomeMy WebLinkAboutSWG2021-000480 APPLICATION FOR EXTENSION - SWG Application - 1/28/2021 MASON COUNTY 415N BTHELTON: 60427- 70,EY7400
SH STREET,
,SHEL ON,W 985M
4 BELFAIR:360-2754467,EXT 400
Public Health & Human Services ELMk 360482b 69,EXT 4W
FAX:360-427-7787
On-Site Sewage System Permit: SWG2021-00048
APPLICANT Mark Churchman Phone: 509-670-2453
Address: 414 Kingsway NW BREMERTON,WA 98312
OWNER Mark Churchman Phone: 509-670-2453
Address: 414 Kingsway NW BREMERTON,WA 98312
SEPTIC DESIGNER PAULA JOHNSON' Phone: 360-898-2255
Address: 171 E VUECREST DRPJE UNION,WA 98592
Site Address: 130 NE Tiger Lake Rd W
Primary Parcel Number: 123052100102
Permit Description: New three bdrm.pressure trench
Permit Submitted Date: 01/28/2021
Permit Issued Date: 0210812021
Issued By: Luke Cencula
Current Permit Fees Paid: $870.00 Ieee�eo„el roes mar m requlree eaoo ms�allafon or srsreml.
Permit Expiration Date: 02/0412026 Ibesea on eeb m m:oecuon)
Permit Conditions:
1 Proposed development subject to zoning requirements and approval by the planning
department staBper 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.
7 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is
obtained
8 Installer responsible for proper 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.govihealthlenvimnmentalionsheloss-inspection-request.php or wll:
360-427-9670,extension 400.
MASON COUNTY 415 NSaE FO RE36027544607 EXT
XT8400
MWPublic Health & Human Services
APPLICATION FOR
/EXTENSION Mqy /�
By.
Amount Paid: ( ��• �(l
Receipt Number:
Instructions: Applicant to complete Parts 1 and 2 and septic designer/engineer to complete `
Part 3. Submd application with extension
r idfee. Make check payable determine f the extension be approved.
Mason County
Treasurer. Staff will review your application�cation n
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
nn ..-0. rj� Phone: S-'Oq—( TO
Z`PS3
Name of Applicant: . l
Mailing Address of Applicant: 4 (4 K S s'b
City:
State: '` 4 Zip: qj 1,
12-digit Tax Parcel Number: 2 S-ZA — 00( fl Z
Site Address: I 3 Z 'C'.
Permit Number. SWG 2-(D?—k — OE70�kfg
Mq yZ
ECE/VED
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 DESIGNERIENGINEER 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.
IDesinner . SCzmp:� I
�9
Signature of Designer/Engineer Date I Q Vic JOHNSON'�."
Comments/Conditions:
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
0 Extension Denied
AJ Extension Approved New Expiration Date:
/Comments: /� ^D^_
Environme H alth Specialist Signature: AP pp, VF®
t MAY2 01014
M7SONCOUNrypNV�O�q
Thi form may be sunned and available for public view on the Mason Cp}�ty*&*4trN
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