HomeMy WebLinkAboutSWG2021-00288 - SWG Application / Design - 5/24/2021 (2) MASON COUNTY 415 N6THELTON: 60427 670,EXB564
SHELTON:360-0274670,EXT 400
BELFAIR:380-2754487,EXT 400
Public Health & Human Services ELMA:360-0825269,EXT 400
FAX:360427-Tr87
On-Site Sewage System Permit: SWG2021-00288
APPLICANT MUSSELMAN DAVID A&DEBORAH C Phone: 360.932.1619
Address: 990 KAZAC PL SE PORT ORCHARD,WA 98366
OWNER MUSSELMAN DAVID A&DEBORAH C Phone: 360.932.1619
Address: 990 KAZAC PL SE PORT ORCHARD,WA 98366
SEPTIC DESIGNER Lawrence Purdum Phone: 2535099922
Address: PO Box 801 Gig Harbor,WA 98335
SEPTIC INSTALLER TESSA HOLT* Phone: 360-349-5333
Address: 4225 BLACK LAKE BLVD SW OLYMPIA,WA 98512
Site Address: WA-302
Primary Parcel Number: 122167590032
Permit Description: New Sbd pump to gravity
Permit Submitted Date: 05124/2021
Permit Issued Date: 0911312021
Issued By: Rhonda Thompson
Current Permit Fees Paid: $895.00 (additional ees may as moaned!upon Installation o1 system).
Permit Expiration Date: 0 610112 0 2 6 ) (bases on date a 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 speed 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/Enginee,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.
7 No septic system installation work may begin until BLD2021-00488 has been issued.
THIS PERMIT MUST BE ONSFE 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/onvironmentaUonsitaloss-inspection-request.php or call:
3604279670,extension 400.
MASON COUNTY 415N6-STREET,SHELTON WA 98584
SHELTON:360-4275670,EXT.400
40 Public Health & Human Services BELFAIR: 360-275554446�67,EXT.400
APPLICATION FOR EXTENSION CAS D
Amount Paid: I J N4comp
Receipt Number: Z0Z11- pG/(p/Z
By_
Instructions: Applicant to complete Parts 1 and 2 and sepfic designer/eng er o
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: Debbie Musselman Phone: 916-730-4286
Mailing Address of Applicant: I&A ue- PL St---
City: cpirej-4ij State: (,UOr Zip:
12-digit Tax Parcel Number 12216-75-90032
Site Address: 51 E PENDRAGON DR, BELFAIR, WA
Permit Number: SWG 2021-00288
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
Septic permit is now expired, need an extension for BLD2024-00988 to issue.
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.
10-28-24
gSignatf Design Engineer Date
230136
O: JUSnN W COOPER
Comments/Conditions: 'otron'dr= nick..
EXPIRES 06/24/2025
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
,,❑ Extension Denied '7
Extension Approved New Expiration Date: I L6
omments:
Environmental Health Specialist Signature:
VIN I"
This form may be scanned and available for public view on the Mason County Web site.
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