HomeMy WebLinkAboutSWG2021-00595 - SWG Application / Design - 10/25/2021 (3) LTON,
WA
® MASON COUNTY 415N B SHELTON: ,SHE7-967 ,EXT,W0
SHELTON:360-02]98]e,EXT 4a0
BELFAIR:360-2]5<46],IXT 400
Public Health & Human Services ELMA:3604a2-5269,EXT 4M
FAX:360427-7787
On-Site Sewage System Permit: SWG2021-00595
APPLICANT MARCINKO FRANK A&SUZE MARIE Phone: 360.621.3121
Address: 5677 MINING LN NW SEABECK,WA 98380
OWNER MARCINKO FRANK A&SUZE MARIE Phone: 360.621.3121
Address: 5677 MINING LN NW SEABECK,WA 98380
SEPTIC DESIGNER FRANK MARCINKO* Phone: 360-801-0147
Address: 5677 Minnig LN NW SEABECK,WA 98380
Site Address: 400 NE Trudeau Mountain Rd
Primary Parcel Number: 223027590100
Permit Description: New SFR-3BR Gravity wt waiver to 18"vs
Permit Submitted Date: 10/25/2021
Permit Issued Date: 1112 4/2 0 21
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $640.00 (addiuenaueea maybe re,iox.wni„sb,nauon orersrere4
Permit Expiration Date: 1111712025 (based on dale or me9e,don)
Permit Conditions:
1 Proposed development subject to zoning requirements and approval by the planning
department staBper Mason County Title IT.
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 barATll 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.govlhealthlenvironmentallunsiteloss-inspecticn-request.php or call:
360427-9670, extension 400.
MASON COUNTY 415 N 6N STREET.SHELTON WA 98584
40
SHELTON:360-427-9670, EXT.400
Public Health & Human Services BELFAIR:360-275-4467, EXT.400
APPLICATION FOR EXTENSION °k
Amount Paid: 6 S o
Receipt Number: 204' - 6y285
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: f'Pa-h�a-^'c�- �uz2 /!A"/n�o Phone:
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Mailing Address of Applicant: ✓ Al AlC�f� /", �4
City: 5'ea1eri state: ie,4 zip:
12-digit Tax Parcel Number: c2 02 300z - 2,S- / a/0/0
Site Address: Zl OO NE rr ua//ea4, /l f /f,(
Permit Number: SWG 12 0 e2 1 - 00S! T
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.
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 Gr/ eer5twip
Signature of Designer/Engineer Date20100110
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Q Fmk A.Mari
LICENSED DESIGNER
Comments/Conditions: — /— — — — — — —
Z a �f refwaned Z"'4 Ile%Q�4
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied h -25-
Exlension Approved New Expiration Date: a:k
Comments:
E i nmental Health Specialist Signature:
h or may be scanned and available for public view on the Mason County Web site.
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