HomeMy WebLinkAboutSWG2021-00146 - SWG Application - 9/4/2024 T,SHELTON WA 98584
MASON COUNTY 415 NSHELTONE36042796 0 EXT.400
f-- Public Health & Human Services BELFAIR:360-275-4467, EXT.400
APPLICATION FOR EXTENSION
CO
Amount Paid: 1
Receipt Number: c- 4 ---2011,3
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: Andre Rowe ET UX Phone: (509) 294-6067
Mailing Address of Applicant: 7002 149th St. E
City: Puyallup State: WA Zip: 98375
12-digit Tax Parcel Number: 22223-51-05020
Site Address: 1291 E.Trails End Dr.,Belfair,WA 98528
Permit Number: SWG SWG2021-00146
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
Project has been delayed as State and local code compliance and approves have been navigated.
This form may be scanned and available for public view on the Mason County Web site.
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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.
L)isigner/Er+ veer Stamp
tiff
2Zeotthginer 03Sept2024 Date ',,
03 Sept 2024
Comments/Conditions:
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied / j
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Extension Approved New Expiration Date: LI I ' Z G
+Comments:
Environmental Health Specialist Signature:
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This form may be scanned and available for public view on the Mason County Web site.
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