HomeMy WebLinkAboutUntitled (466) rirOWMASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
On-Site Sewage System Permit: SWG2022-00034
APPLICANT DEAN CONSTANCE J Phone:
Address: 24209 NE 14TH ST CAMAS, WA 98607
OWNER DEAN CONSTANCE J Phone:
Address: 24209 NE 14TH ST CAMAS, WA 98607
SEPTIC DESIGNER Jim Zimny Phone: 360-516-7287
Address: 7178 WINDFLOWER PL NW SEABECK, WA 98380
Site Address: XXX W Lakeside Dr
Primary Parcel Number: 519015002010
Permit Description: New three bdrm-gravity bed w/extension
Permit Submitted Date: 02/01/2022
Permit Issued Date: 02/23/2022
Issued By: Luke Cencula
Current Permit Fees Paid: $665.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 02/10/2027 (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 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 Designer/Engineer 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 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: masoncountywa.gov/health/environmentallonsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
0. 111. ....,.._: MASON COUNTY 415 N 6T"STREET, SHELTON WA 98584
SHELTON: 360-427-9670, EXT. 400
Public Health & Human Services BELFAIR: 360-275-4467, EXT. 400
APPLICATION FOR EXTENSION
Amount Paid: ,l6S,0t2
Receipt Number:
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.
RC* ‘.14111141■1104•Pailt
PART 1: APPLICANT AND PARCEL INFORMATION
Name of Applicant: t`3 sI 9 Op .,, Phone:
Mailing Address of Applicant: 7tH 7 o N 6' v-H-h S 4--
City: C 6,vL i 4, s State: f4 (N- Zip: is7Lceri
12-digit Tax Parcel Number: S 1 I' o L - S o - 0 2 0 I 0 pcnu '
TMSite Address: 1 4 dk_ ( a 4— .tl= /o
81/ MAR 12 2025 Ld
Permit Number: SWG 70 22-- 0v639 -4
BY:
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
'
This form may be scanned and available for public view on the Mason County Web site.
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e 1 of 2
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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.
Designer/Engineer Stamp:
2_ ciss
►
•
Signatu e Designer/Engineer Date Y �,►►
►►►
i
LICy .DESIGNER ►
Z ?- 2S
Comments/Conditions:
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied //
L( Extension Approved New Expiration Date: ?( ( 2/?tZ
Comments:
Environmental Health Specialist Signature: MAR 1
R(4SONCQf/NryE 2015
/Ntr/RONMtNr
This form may be scanned and available for public view o'Yt a Mai bounty Web site.
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