HomeMy WebLinkAboutSWG2024-00126/APPLICATION FOR EXTENTION - SWG Application - 5/3/2025 at .: MASON 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: SWG2024-00126
APPLICANT Melissa Fulton Phone: 360-522-7001
Address: 330 E Queens Way OLYMPIA, WA 98506
OWNER Melissa Fulton Phone: 360-522-7001
Address: 330 E Queens Way OLYMPIA, WA 98506
SEPTIC DESIGNER CINDY WAITE* Phone: 360-701-0205
Address: 80 E PICKERING LANE SHELTON, WA 98584
SEPTIC INSTALLER THAD BAMFORD* Phone: 360-790-2364
Address: 301 WALLACE KNEELAND BLVD STE 224-332 SHELTON, WA 98584
Site Address: 330 E Queens Way
Primary Parcel Number: 221295200009
Permit Description: Repair-2BR Pressure (oversized) with expiration extension
Permit Submitted Date: 04/01/2024
Permit Issued Date: 04/04/2024
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $970.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 05/31/2025 (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 Drain field 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.
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/environmental/onsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
4
. ; •.- , MASON f ,�
'iJ 415 N 6 STREET, SHELTON WA 98584
'0 .i SHELTON:360-427-9670, EXT.400
' S‘srivcesBELFAIR:360-275-4467, .400
,iicta-4,,,,wom--7---1 -417iiii.,-,..--cra.wirdia.-.--i--4,15:37.4,7,-;. . -.11..,,ye-wt..t. a,-;;-:;,7.-,,,- ;.,--:iza ..s-,,a,,,,,,—;',—.17.0.v---....,,,,..-7,—.-..,-.,,, . .. .% .4.--
APPLICATION FOR EXTENSIO " %, 195 _
Amount Paid: it Lc-5_
Receipt Number:-_20j17- ozard
instructions: Applicant to complete Parts 'i and 2 and septic designer/engin 96.1 o 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 re ' ire a renewal, -
4
�aaMxn+rsW^-a-A.�:�"iavvr "RMA41(Y+NhMAviP.VC�b."M".+itra..11 Z}:MM:,tENy1,9L=,'TnctTA4Y=ei`.IIiaO:YWJR6d.J1.31M�iY:..0.-+A'J,\. "•--.•.-•-•..•..••••---��
i • PART I: APPL iCANI r AND PARCEL, lNFORMM4TioN 340 SZ1-7.00 l
Name of Applicant. .tt. U. V1 Phan —4 0`:
0 Mailing Address of Applicant: .3: C -IS. LO
State: —� Zip: /'
City: 51,e-i;12-digit Tax Parcel Number:_Z2/2- " 52-- oC h-)9
�
Site Address: 3-7-X-2- L 4---'1 W 6'w� {,46►"-? 1 v4J /� c:t
Permit Number: SWG Z-2` " °(5 1.2-c. ,.
+riii r+ii+y""r a a'•ax`t-s:...n ea:anwrzisi�usyss.vevust.akei+ca-....--atcc'rT,er:m<m...-.iar<i% vq:.w.c.rovecac+rctxL:us:-4:uz.vw:samara•LL.A•-- �'-1111 1iw arisi:
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
1 Ypc2: 4*?) ie:). z- t�4N". �= P•c-e) y�4a�u luz..(-b0-rr .--j ..-�y\.,' .„_
4
4 This form may be scanned and available far public v wv on i:he € aso:: Count:;!Weti site.
4
Pag, 1 of 2
41
--•.a.-.T ..iial,-_-::5..ems: .criiie:.F:u ¢iiia. ;a,-.4,17,1Mu s r c ii.s:axn::n`so'.s:- .:.`an,ems:._.
PART 3: ORIGINAL DESIGNER/ENGINEER REVIEW AND APPROVAL
I, the undersigned original Designer/Engineer, attest that I have reinspected the p r
found the following conditions to be true as of the date of my signature below: operty and
• NO part of the proposed Drainfield or Reserve area has been altered or di
a way that may render the proposed design invalid. sturbed in such
• NO development has occurred on this parcel or neighboring parcels which would c
the proposed system to no longer meet minimum setbacks. Ouse
• NO Boundary line adjustments or subdivisions have occurred which would
cause the
property to fail below the minimum land area requirements of WAC 246-272A.
•
(34c4 —
Signatur f Designer/Engineer ~ • .F:;,
Date i ' ��
d r. r-1� 8 1_ �� /
Erc ;L ,� I
Comments/
li
—..11_114.1__k eV le'fa---_____1*___IaLn- 42.2 .
i'U'�v�tia:::,,;': z:+v�M:;a�sa,maw.ems.-- i.��.c..._.<_—=_�.-.:.::. -
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
C] Extension Denied •
yl Expiration Date:Extension Approved New
Comments: / ��
Environm ntal Health Spe 'alist Signature: C k '. kf;,,, .
4ASON /1/4y0 2 242,5
:'�: f..
•
This for ay be scanned and available for public
l,a`°�`��Mason County Web site,
H�4LTy
Page 2 of 2