HomeMy WebLinkAboutSWG2022-00436 APPLICATION FOR EXTENSION - SWG Application - 8/22/2025 a : MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
BELFAIR'.360-275-4467,EXT 400
f' Public Health & Human Services ELMA.360-482-5269,EXT 400
FAX.360-427-7787
On-Site Sewage System Permit: SWG2022-00436
APPLICANT Smith, Earl Phone:
Address: PO Box 1876 SHELTON,WA 98584
SEPTIC DESIGNER ADAM HUNTER* Phone: 360-753-1226
Address: PO Box 162 OLYMPIA, WA 98507
Site Address'. 1003 W Kamilche Ln
Primary Parcel Number: 319074490043
Permit Description: New Commercial 600 GPD-sand-lined beds (LOT 3)-REVISION with
extension
Permit Submitted Date: 08/04/2022
Permit Issued Date: 08/25/2022
Issued By: Luke Cencula
Current Permit Fees Paid: $1,485.00 (,mdamoal tees may be required upon instdlL'lion or system).
Permit Expiration Date: 08/12/2027 (based or'dale of mspecmo)
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.
48"to bottom of bed(sand bottom); 24"to top of sand.
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 Gravel-less chambers required per design.
8 Two risers to grade required on pump tank.
9 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is
obtained
THIS PERMIT MUST BE ONSITE DURING INSTALLATION OF 055.
PROPERTY OWNERS ARE RESPONSIBLE FOR DETERMINING AND MARKING ALL PROPERTY LINE AND EASEMENT LOCATIONS.
THIS PERMIT MAYBE 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/onsite/oss-inspection-request.php or call:
360-427-9670, extension 400.
MASONCOUNTY 416 NSHELTON::360-427-98 0 EXT.400
Public Health & Human Services BELFAIR:380-275-4487.EXT.400
irkZECIVPATI
APPLICATION FOR EXTENSION AUG 2 ?Pk
Amount Paid: )��, 1,•• BY-
Receipt
Number: ,4k 2.? -bci l
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:jjAkSC l�bi&r V�I2IOd3I I'E 1j1.('Mt t$hone: L' LZ�-�gC J
Meiling Address of Applicant: t •V . <<-1.%� ,t
_. I 1 ��
city: MAC- C, 1iy ➢ StiiMel1: ��l 11 zip: • J
12-digit Tax Parcel Number: 3 is-m7-Y '1- -f( i( i`r
Site Address: pp.��)��3�--7 Lan L I, kke ( ✓I
•
Permit Number SWG L— LZ— U.-''1B(t''
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
y3(_lL U7yr ; billies ed�d-
This form may be scanned and available for public view on the Mason County Web site.
Page I or 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/En - BrS p'. 7 2
Si ture of Designer/Engineer Date
Comments/Conditions:
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied r� /'7
Extension Approved New Expiration Date: 5J 7 / 2 I LOZ7
Comments: d ^
Environmental Health Specialist Signature: P�®
`c q0016Zo1S�F®
This form may be scanned and available for public view on the Mason Couii*q site.
Page 2oi ,S