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Home My WebLink AboutSWG2020-00563 APPLICATION FOR EXTENSION - SWG Application - 10/21/2020 415 N 6TH STREET,SHELTON,WA98584 SHELTON:360<27 ENT 400 MASON COUNTY BELF MA:360482-5269,ENT 400 Public Health & Human Services ELMA:3 0FAX:360 FXT400 FAX:380<27-7]B] On-Site Sewage System Permit: SWG2020-00563 APPLICANT OLDRIGHT ROBERT& MARY J TRSE Phone: 253-677-0373 Address: PO Box 1197 MILTON,WA 98354 OWNER OLDRIGHT ROBERT&MARY J TRSE Phone: 253-677-0373 Address: PO Box 1197 MILTON,WA 98354 SEPTIC DESIGNER JUSTIN RUSSELV Phone: 360.956.7242 Address: PO BOX 14531 TUMWATER,WA 98511 Site Address: 9091 NE NORTH SHORE RD Primary Parcel Number: 222183400020 Upgrade 4bd pressure trench on easement wl permit expiration Permit Description: extension Permit Submitted Date: 1012112020 Permit Issued Date: 03/11/2021 Issued By: Rhonda Thompson Current Permit Fees Paid: $630.00 Iaeaniwal ma:may a,neawea apoa msiallauon ofsx=oeml Permit Expiration Date: 11/0212026 (basedasdatedimpedoa) 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 specked 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 bawl/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: masonmuntywa.gov/health/anvimnmental/onsiteloss-inspection4equest.php or call: 360.427-9670,extension 400. SHELTON WA MASON COUNTY 415 N 6�STREET,SHELTON 60-427960 EXT.400 BELFAIR:360-275-4467,EXT.400 Public Health & Human Services APPLICATION FOR EXTENSI APR I l 1015 Amount Paid: 11(.J5 Receipt Number: 2af mix gy 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: K Phone: b�7 '�73 Mailing Address of Applicant: P.D. RCc I 147 city: M 1 L-r0jQ State: w 4 Zip: 12-digit Tax Parcel Number: -2 7 2 (S 3` 0f® 2 c> Site Address: !3 04 I N e Y-jo"'[S 1-IDtL6 ?- Permit Number: SWG a(220-012S63 PART 2: EXPLAIN WHY YOU NEED AN EXTENSION �usracivG zr�View This form may be scanned and available for public view on the Mason County Web site. Pape 1 of 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. IDesigner/Engineer Stamp: I 41 a/zs � */za � Si n//ature of Designer/Engineer Date I Y. I b .2 w I ......W�.N S.•4S4^ir_-- I I _I Comments/Conditions: 170YI fJO)ATH SKoRIE RD PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only) ❑/Extension Denied /► �` / t� Extension Approved Nev1E lit)e Date r (Comments: "�f O Environme t Health Specialist Signature: SON000Nry ,4 FN z01f OJqONMet4l//F This form maybe scanned and available for public view on the A35on County Web site. Page 2 of 2