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Home My WebLink AboutSWG2021-00158 - SWG Application / Design - 3/29/2021 (2) SHELTON.WA MASON COUNTY 415NBTHELTON: , 0427-97 ,EXT 404 SHELTON:360-427-9870,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: SWG2021-00158 APPLICANT Brian Johnson Phone: Address: 510 Drew St BAKERSFIELD, CA 93312 OWNER JS BUSINESS ENTERPRISES Phone: 1.253.820.5077 Address: 130 SE TOTTLYN RD SHELTON,WA 98584 SEPTIC DESIGNER TOM WEAVER' Phone: 360-620-7054 Address: 3912 STEELHEAD DRIVE NW BREMERTON, WA 98312 Site Address: XXXX E Agate Rd Primary Parcel Number: 220185500006 Permit Description: New SFR-38R Nuwater+Oscar w/extension Permit Submitted Date: 03/29/2021 Permit Issued Date: 09/22/2021 Issued By: Jeff Wilmoth Current Permit Fees Paid: $640.00 (addidonal fees may be reawred upon msvllaaon of system). Permit Expiration Date: 03/30/2026 (based on dale ofinspeclion) 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 back(II 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. 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/environmentaYonsiteloss-Inspection-request.php or call: 360-427.9670,extension 400. 40 MASONCOUNTY 416 N 6TM STREET,SHELTON WA 986M SHELTON:360427-9670.EXT.400 Public Health & Human Services BELFAIR:3 60-2 75 416 7,EXT.400 32"21 00 15>s APPLICATION FOR EXTENSION Amount Paid: MAR 21 2025 — Receipt Number: 2025• p 17b2 BY 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: TEirS S7/2 A. T>—c,N Phone: 41-9— o 40 - S-07-7 Mailing Address of Applicant: O C � T-� = L Y, / P 0c city: S H P I- 7-6AI State: W4 zip: ./v5-R`I 12-digit Tax Parcel Number. /8 -AS- 0000 6 Site Address: S"7. 9/ E AC Al C A$V S'//ct ion/ 76SYg Permit Number: SWG 2- O 7 I - On L.6 6 PART 2: EXPLAIN WHY YOU NEED AN EXTENSION f EL1f �S /rd Part /"I T-, ^ 4 �'/{oC �sS 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. Designer/Engineer Stamp: I Signature of Designer/Engineer Date I r a I THOAVSE AVER', NSEn f WEN Comments/Conditions: ��rr� — — — — — [ 20TGCi iy F/ELD 'dn Cam/ l0A/ST.1. Tin /L/ PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only) ❑ Extension Denied /J 7 Extension Approved New Expir ion Date. Comments. A A Environmental Signature: '14S0*00 y Mq�2�20js / ENS/NO �✓ NMFNT This form maybe scanned and available for public view i�n the 111.1p�nTCounty Web site. H Page 2 02