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Home My WebLink AboutSWG2021-00469 EXTENSION - SWG Application - 11/21/2024 ON, MASON COUNTY 415N B SHELTON: ,SHELT967 ,EXT 404 SHELTON:380<27-9870,EXT 400 BELFAIR:360-275d487,EXT 400 Public Health & Human Services ELMA:360482-5289,EXT 400 FAX:360-427-7787 On-Site Sewage System Permit: SWG2021-00469 APPLICANT DONJON JOHN C &PATRICIA A Phone: Address: 4760 MELISSA JO LN SAINT LOUIS, MO 63128 OWNER DONJON JOHN C&PATRICIAA Phone: Address: 4760 MELISSA JO LN SAINT LOUIS, MO 63128 SEPTIC DESIGNER Jim Zlmny Phone: 360-516-7287 Address: 7178 WINDFLOWER PL NW SEABECK,WA 98380 SEWAGE INSTALLER MIKE SKINNER' Phone: 360-710-6489 Address: 4454 AHERN CT W PORT ORCHARD,WA 98367 Site Address: 231 E KILMARNOCK RD Primary Parcel Number: 321275400075 Permit Description: Now two bdrm-Nuwater trench Permit Submitted Date: 08109/2021 Permit Issued Date: 09/07/2021 Issued By: Luke Cencula Current Permit Fees Paid: $905.00 (addbonai laaa may a reuire upon maanamn ar aya ). Permit Expiration Date: 08/2612026 (basadondalea(,napa n) Permit Conditions: 1 Proposed development subject to zoning requirements and approval by the planning department staBper 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 Drainfieid installation not to exceed designed upslope(14") and downslope f7�depth specified on design form. Minimum 6"cover material required. 4 Installer is responsible for obtaining Mason County installation approval prior to backfil/of system components. 5 Installer is responsible for obtaining Septic Designer/Engineer installation approval prior to backfill of system components. 6 Mason County AsbuiO Form, Record Drawing, and Installation fee must be submitted for final installation approval. 7 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is obtained 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: masonmuntywa.gov/health/environmentallonsite/oss-inspection-request.php or"It: 360-427-9670, extension 400. MASON 'COUNTY 415 NSHESTREET, SHELT 0 WA 985&4 EXT 400 Public Health &IHuman Services BELFAIR. 360-2754467,EXT.400 APPLICATION FOR EXTENSION Amount Paid: s (a� am Receipt Number. ' UEq— � J't.r _IJ 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 Phone: Mailing Address of Applicant Sf ti 4.A . City: S..)..k- L ..;4 State. /"t e zip: L-1. I ZFi 12-digit Tax Parcel Number: Z 1-7,2 S 4 ben 7 T- Site Address. Zb f E K: I m a_r. a cjc RG t S A6I1�.r Permit Number: SWG 2u'Z,t —Ooe/(erq PART 2: EXPLAIN WHY YOU NEED AN EXTENSION 4t 14, t h I� ' ti �,� lit 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. I I I Signatur of D gner/Engineer Date I I I i/-2d Zy I I Comments/Conditions. — — — — — — — — PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only) ❑ Extension Denied fExtension Approved New Expiration Dater omments: Environmental Health Specialist Signature: This f rrn may be swnnad Ind available for public view on the Mason County Web sibs. P.,2 oft