HomeMy WebLinkAboutSWG2021-00595 - SWG Application / Design - 10/25/2021 (2) 475NB
® MASON COUNTY H STREET, LTON, A 9 70,EXT 84
4M
H ELTON: S SHEHE T O
S
BELFAIR:380.2754487,EXT 4W
Public Health & Human Services ELMA:360Ja 69,EXT 4M
FAX 360i27-7707
On-Site Sewage System Permit: SWG2021-00595
APPLICANT MARCINKO FRANK A&SUZE MARIE Phone: 360.621.3121
Address: 5677 MINNIG LN NW SEABECK,WA 98380
OWNER MARCINKO FRANK A&SUZE MARIE Phone: 360.621.3121
Address: 5677 MINNIG 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 wl waiver to 18"vs
Permit Submitted Date: 10125/2021
Permit Issued Date: 11/24/2021
Issued By: Jeff Wilmoth
Current Perna Fees Paid: $640.00 ladduonai leas me,m reaoired upon installation ureyelem7.
Permit Expiration Date: 11/17/2025 (Weed on dma era0eeaion)
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 backfill of
system components.
5 Installer is responsible for obtaining Septic Designer/Engineer installation approval prior to
backfi/I 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/Gss-inspection-request.php or call:
360.427-9670, extension 400.
MASONCOUNTY 415 NSHELTON 360-427960,EXT.40
Public Health & Human Services 6ELFAIR:360-275-4467,EXT.400
A
APPLICATION FOR EXTENSION }
Amount Paid:
Receipt Number: &Z - 0N2R
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: ��I�IA--.M /' Phone: 36 O BB/•O/�7
Mailing Address of Applicant: .SY%7 /'� i�nG9 LA W
City: 5!eRh1Lti State: Lf/A ZiP: IrP441
12-digit Tax Parcel Number: a2 a2 30 a ^ 7S 90100
Site Address: Il00 AE I-rac%ati /Y14 /Le(
Permit Number: SWG
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
Qy E. 1 -a fw0 kart a Y`ZWt /� 1' N /as7� 21/ A"AlZPI
tr�xr / Jrl�kh
..re
r„ro616 kwZok /M1 A A A maner. ZLw4les4r rr�r /�fie/Mg2n / S� 1t��
>t
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.
Designer/ eer Stamp:
I I
NX
Signature of Designer/Engineer Date I / J �
Freak A.Mordnko
ILICENSED DESIGNER I
Comments/Conditions: 9 — — — — — — — —
�,�ft � � S rel..a.�ned rin- eve%0��
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied t'D -Z.S- ;?s
Extension Approved New Expiration Date:
Comments:
E/R i nmental Health Specialist Signature:
h or r may be scanned and available for public view on the Mason County Web site.
Page 2 of 2