HomeMy WebLinkAboutSWG2021-00031 APPLICATION FOR EXTENSION - SWG Application - 1/25/2021 HELTON,WA
584
MASON COUNTY 416N8THELTON: , 0427-97 ,EXT 400
SHELTON:360-27 - 70,EXT 400
BELFAIR:360-275-0487,EXT 400
Public Health & Human Services ELMA:360482.5269,EXT 400
FAX:360-427-7787
On-Site Sewage System Permit: SWG2021-00031
APPLICANT HAYS GARY L&CATHY J Phone: 360-620-4442
Address: 3180 E MASON LAKE DR W GRAPEVIEW, WA 98546
OWNER HAYS GARY L&CATHY J Phone: 360-620-4442
Address: 3180 E MASON LAKE DR W GRAPEVIEW,WA 98546
SEPTIC DESIGNER PAULAJOHNSON* Phone: 360-898-2255
Address: 171 E VUECREST DRIVE UNION,WA 98592
Site Address: 361 E EMERALD LAKE DR EAST
Primary Parcel Number: 321245000068
Permit Description: New 3bd ATU pressure trench
Permit Submitted Date: 0112512021
Permit Issued Date: 02/09/2021
Issued By: Rhonda Thompson
Current Permit Fees Paid: $640.00 (additional fees may be,eem,ed ,on mstaneon or system).
Permit Expiration Date: 02108/2026 (based on date of 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 Drainffeld 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 DesignenEngineer 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/healthionvironmental/onsiteloss-inspection-mquest.php or call:
360-427.9670, extension 400.
MASONCOUNTY 4 SNSHELTON:360-427-96 0 EXT.400
BELFAIR:360-275-M67.EXT.400
Public Health & Human Services
APPLICATION FOR EXTENSION �WIMR71 'i�
Amount Paid: . I USE)-- JAN 2 2 2025
Receipt Number:015--430216 i
BY---
instructions: Applicant to complete Parts 1 and 2 and septic designer/engineer to COMMIT-------
Part3. 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 Specialists
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: � -y�0.'.. s --- Phone:
Mailing Address of Applicant: e'
City: � �"'1 State: ( Zip: "'—
. 12-digit Tax Parcel Number: �72'� 2,* — -50—
Site Address: ew e� LA4�0— b-t E r�=�t teW
Permit Number: SWG 2A 2-t — O00 3
11,
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
This form may be scanned and available for public view on the Mason County Web site.
P,v 1of 2
PART 3: ORIGINAL DESIGNERIENGINEER 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.
2s I I
Signature of Designer/Engineer Date I ~nPPAULAA JOY JOHN60N `
I C fSS b 'i^Ti It" +
jRES? 2 zs
Comments/Conditions:
- - - - - - - -
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied gyp,
Extension Approved New Expiration Date. U 2'
Comments:
Environmental) He�althh Specialist Signature:
This form may be scanned and available for public view on the Mason County web site.
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