HomeMy WebLinkAboutSWG2021-00566 - SWG Application - 10/12/2021 584
MASON COUNTY 4r5N8SHELTON: , 0427-97 ,FXT 400
SHELTON:380-2754 7,EXT 400
BELFAIR:380-275-4457,EXT 400
Public Health & Human Services El-i 360482-5269,EXT 400
FAX:360427-7787
On-Site Sewage System Permit: SWG2021-00566
APPLICANT GREG HOSLEY Phone:
Address: 125 DAVENPORT ST BORGER,TX 79007
OWNER GREG HOSLEY Phone:
Address: 125 DAVENPORT ST BORGER, TX 79007
SEPTIC DESIGNER CINDY WARE-Septic Designer Phone: 360-701-0205
Address: 80 E PICKERING LANE SHELTON, WA 98584
Site Address: N Olympic Trails Dr
Primary Parcel Number: 324345000042
Permit Description: New 2bd gravity bed
Permit Submitted Date: 10/12/2021
Permit Issued Date: 12/20/2021
Issued By: Rhonda Thompson
Current Permit Fees Paid: $640.00 (additional lees may be repwnsd upon installation of system).
Permit Expiration Date: 10/14/2026 (based on dale or inspection)
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 Drainfeld 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 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.
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: masonwuntywa.gov/health/environmentaVonsiteloss-inspection-request.php or call:
360-427-9670,extension 400.
MASONCOUNTY 415 NSHELTON:60-427960 EXT.400
Public Health & Human Services BELFAIR:360-2754467,EXT.4Q0
APPLICATION FOR EXTENSION r; �• ';
I r '
Amount Paid:
Receipt Number:
1
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 r'
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:
CHRISTINIA LANE Phone: 619-775-7207
Mailing Address of Applicant:
501 N OLYMPIC TRAIL DR
City: LILLIWAUP State: WA Zip: 98555
12-digit Tax Parcel Number: 32434-50-00042
Site Address: XXX N OLYMPIC TRAILS DR
Permit Number: SWG 2021-00566
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
BUILDING PERMIT IS NOT APPLIED FOR AT THE TIME, WILL BUILD NEXT YEAR
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
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.
Design hg erstamp:
Ilk 7-ozy L
Signature of,0esigner/Engineer Date
Y LICE 9 DESIGNER
E%i-0R[5 OY10i
I
Comments/Conditions: — "— — — — — — —
Gcc�� jf
00-1oe4miLc.( 5.7� �ofS 4cG sL.l�i�
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied
Extension Approved New Expiration Date:
omments:
Environmental Health Specialist Signature:
This form may form may b� andand a�for putt on the Mason County Web site.
Page 2 of 2