HomeMy WebLinkAboutSWG2020-00510 APPLICATION FOR EXTENSION - SWG Application - 12/16/2024 � I
MASON COUNTY 475 NSHE TON:380-4274)670,EXT 400
BELFAIR:3M275-0467. EXT.400
Public(Health & Human Services
APPLICATION FOR EXTENSION D DEC 1 6 2026
Amount Paid �5• U p
Receipt Number: ?y' p By
Instructions: ApPli t to complete Parts 1 and 2 and septic designer/engineer to complete
Part 3. Submit applica ion with extension permit fee. Make check payable to Mason County
Treasurer. Staff will r view your application and determine if the extension can be approved.
Conditions for approv I are outlined in this application.
Prior to or after expire ion of an approved design, the applicant may apply for a permit
extension. The permit (tension shall extend the expiration of the design for up to two years,
but not exceed five y rs from the signature date of the Environmental Health Specialist's
site inspection{Per W C 246-272A-200(4)(e))
All approved septic d igns may receive one extension. Additional extensions shall not be
accep+ed and would i stead require a renewal.
PART 1: APPLIC-AAN AND PARCEL INFORMATION
Name of Applicant: v ) Phone: ��
UNEZ
Mailing Address of Appl' nt
Cdy .Eli �n o rJ S state: Wilk zip: q S o
12•d'igR TS ParestNum 12105Gi 200 aSite Address: bD V E 15 LL W
Permit Number. S . 1010
- 5
PART 2: EXPLAIN *Y YOU NEED AN EXTENSION
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This form maybe canned 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 or final 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 pr sed Drainfield or Reserve area has been altered or disturbed in such
a way that may r nder the proposed design invalid.
• NO development has occurred on this parcel or neighboring parcels which would cause
the proposed sy em to no longer meet minimum setbacks.
• NO Boundary lin adjustments or subdivisions have occurred which would cause the
property to fall blow the minimum land area requirements of WAC 246-272A.
IDesigner/Engineer stamp:
I
12- 1't2
Signatur f esig er/Engineer Date I +'
1 'Z 2 Z Y
Comments/Conditions:
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only) /
❑ Extension Deni$d
fExtension Apprdved New Expiration Date:
omments:
Environmental Heal Specialist Signature:
PAR ; This fort scanned and available for public view on the Mason County Web site.
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