HomeMy WebLinkAboutSWG2020-00599 APPLICATION FOR EXTENSION - SWG Application - 8/8/2024 6�STREET,SHELTON WA
584
MASON COUNTY 415 NSHELTON:360-427-9670,EXT8400
Public Health & Human Services BELFAIR:360-275-4467, EXT.400
APPLICATION FOR EXTENSION
Amount Paid: �t� 6
Receipt NumberD-547-7—
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: Randy Meverden Phone: (209)484-2673
Mailing Address of Applicant: POB 71
City: Lilliwaup State: WA Zip: 98382
12-digit Tax Parcel Number: �62kA ( Z.- IZ— 00 14 Q
Site Address: 61 N RUSTIC RIDGE DR,LILLIWAUP, WA 98555
Permit Number: SWG 2020-00599
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
The Installation permit although paid for and released to the installer by MCPHD prior to the
On-Site Sewage System Application expiring,the installation of the system was not finalized prior to
the On Site Sewage System Application expiring
This form may be scanned and available for public view on the Mason County Web site.
Page 1 of 2
PART 3: ORIGINAL DESIGN ERIENGINEER 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.
IDesigner/Engineer Stamp.
07 Aug 2024 A
lk—
Signature of Design gineer Date I
07 Aug 2024
Comments/Conditions:
The Septic System was installed in accordance with the MCPHD approved On-Site Sewage
System Application,No part the proposed Primary or Reserve Drainfield have been altered,
o-development as occure on a sir je or neig onng parce w Ic wou a ec -etbacR
requirements and No Boundry line adjustments or subdivisions have occured.
The Septic System was installed prior to the MCPHD approved On-Site Sewage expiring,
although the system was not inspectled and signed off by a MCPHD sanitarian prior to the
On-Site Sewage System Application expiring.
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied
IExtension Approved New Expiration Date:
mments:
Environmental
�Health
Specialist Signature:06 I iiz�)P-M
This form may be scanned and available for public view on the Mason County Web site.
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