HomeMy WebLinkAboutSWG2021-00562 EXTENSION - SWG Application - 11/11/2024 584
MASON COUNTY 416NBSHELTON: , 0427-9 70 EXT 400
SHELFAIR 360-227-9670,EXT 400
BELFAIR:360-275-0467,E%T 400
Public Health & Human Services ELMA:360-482-5289,E%T 400
FAX:360427-7787
On-Site Sewage System Permit: SWG2021-00562
APPLICANT Arsenia and Virgilo Sumalbag Phone: (206)551-8118
Address: 21613 6th Ave S SEATTLE,WA 98198
OWNER SUMALBAG VIRGILIO ANTONIO JR& Phone: (206)551-8118
ARSENIA DAVID
Address: 21613 6TH AVE S NORMANDY PARK, WA 98198
SEPTIC DESIGNER JUSTIN RUSSELL* Phone: 360.956.7242
Address: PO BOX 14531 TUMWATER,WA 98511
Site Address: UNKNOWN
Primary Parcel Number: 320242190060
Permit Description: New 2bd Glendon M31
Permit Submitted Date: 1010612021
Permit Issued Date: 0310812022
Issued By: Alex Paysse
Current Permit Fees Paid: S I+ddiwnalNasmuroeroau�umn'"ml��nol�rr�N-
Permit Expiration Date: 1110222026 baud oo date a Io ,a.ol
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 Designer7Engineer 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.gov/health/environmentallonsite/oss-inspection-request.php or call:
360.427-9670, extension 400.
MASON COUNTY
415 N BTM STREET,SH e85E4
SHELTON:380-027-9677-9670, E EXT.900
Public Health & Human Services 9ELFAIR:360-275-4467, EXT.400
APPLICATION FOR EXTENSION
Amount Paid: &,` b J
Receipt Number: (� Z�{— Q Lf e C7 Z
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: VI li,_ Phone: .2D& 551 Z11
Mailing Address of Applicant: / , •�
City: � �n�,rrYnAT •P1L State: w� Zip:
12-digit Tax Parcel Number: L3 2O 24' Z I 'l 00 (,U
Site Address: `1 OP1.Q_ t�(�i'f
Permit Number: SWG S02Z1 - 0U56Z
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
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This form May b manned 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 arlgiaaFDesigner/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/Engineer Stamp:
Signature of Designer/Engineer Date I .
'2 2200000/ A
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Comments/Conditions: — — — /— — —
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PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied
) xtension Approved E New Expiration Date:
Co ments:
Environmental Health
Specialist Signature:
This form may 6a scanned and available for public view on the Mason County Web site.
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