HomeMy WebLinkAboutSWG2021-00201 - SWG Application / Design - 4/19/2021 (2) 584
MASON COUNTY 415N6THELTON 0427-9N,WA98400
SHELFAIR 360-275 94]0,EXT 400
BELFAIR:360-2]5-446],EXT 400
Public Health & Human Services ELMA 360482-5269,EXT 400
FAX:360-427-]18]
On-Site Sewage System Permit: SWG2021-00201
APPLICANT NIELSEN VAL J &IRIS L Phone:
Address: 2629 ABERDEEN AVE HOQUTAM, WA 98550
OWNER NIELSEN VAL J &IRIS L Phone:
Address: 2629 ABERDEEN AVE HOQUTAM, WA 98550
SEPTIC DESIGNER CHRIS ELSTROTT' Phone: 360-561-5000
Address: 128 NORTH RIVER STREET MONTESANO, WA 98563
Site Address: 71 W Satsop Bridge Rd
Primary Parcel Number: 619057500010
Permit Description: New SFR-3BR Pressure
Permit Submitted Date: 04/19/2021 ,
Permit Issued Date: 05/03/2021
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $1,130.00 (additional fees may be required upon Installation or system).
Permit Expiration Date: 04/29/2026 (based on dale of 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 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 bacfilill 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.
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/environmental/onsite/oss-inspection-request.php or call:
360-427-9670,extension 400.
16=:
40 MASON COUNTY 415 NW'STREET.
360-4279fi0 EXTWAYx4e0
Public Health & Human Services afLFAIR: 360 275.4457. Ex1. OW
APPLICATION FOR EXTENSION D
�� 5 AUG 2 9 2024
Amount Paid: �)
Receipt Number: By�
Instructions: Applicant to complete Parts 1 and 2 and septic designerlengineer to complete
Part 3. Submit applcafon 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
PART1: APPLICANT AND PARCEL INFORMATION
24
Name of Applicant: __ I LS Ef-� Vt'}L S_ Phone:
Mailing Address or Applicant: _�� wa5-. _ ftfrb--&_=b _ .--
city: _Et__N`�f------- ------- State: w-� --------- Zip: _`%-4 j ---
12-digit Tax Parcel Number:
Site Address: _--it _SA�SOQ gez--ye .JflD— ----.. .----—---—
Permit Number: S W G
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
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This farm may be scanned and available for publk 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 dale 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 WAG 246.272A.
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Signature of DesignerlEngineer Date I a I
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28508,E
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CommentslConditions — — — —' — — —
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied I
Extension Approved New Expiration Date: _ 17—a1 /
ommems:
Environment�al�HeallthSppeciaallistt Signature:
This form may be scanned and available for public view on the Mason County Web sloe.
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