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Home My WebLink AboutSWG2022-00473 APPLICATION FOR EXTENSION - SWG Application - 8/31/2022 415 N 6TH STREET,SHELTON,WA 98584 a., MASON COUNTY SHELTON:360-275-4467,EXT 400 BELFAIR:360-275 4467,EXT 400 360-482-5269,EXT 400 A: Public Health & Human Services ELMFAX:360-427-7787 On-Site Sewage System Permit: SWG2022-00473 APPLICANT DENOTTA DONALD D & CARON M Phone: 4 Address: PO BOX 2366 BELFAIR, WA 98528 OWNER DENOTTA DONALD D & CARON M Phone: Address: PO BOX 2366 BELFAIR, WA 98528 Phone: 360-898-2255 SEPTICddresDESIGNER PAVE VUEECRESLA OTIDRIVE UNION, WA 98592 Address: Site Address: XXXXX E State Route 106 Primary Parcel Number: 222125900009 Permit Description: NEW SFR -4BR Sand lined bed with permit extension Permit Submitted Date: 08/31/2022 Permit Issued Date: 09/06/2022 Issued By: Jeff Wilmoth $935.00 (additional fees may be required upon installation of system). Current Permit Fees Paid: Permit Expiration Date: 08/31/2027 (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 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: masoncountyw3 Uo-4v27 9670eextens on 400.nsiteloss-inspection-request.php or call: STREET, SHELTON WA 98584 J LMgsp N COU NTY 415 NSHELTON: 360-427-96 70, XT.400 ��--- Public Health & Human Services BELFAIR: 360-275-4467, EXT.400 TION FOR EXTENSION P(°1-°117//ifilAPPLICA Li AUG 2 b 2025 ig Amount Paid: V..D 5 ' ► Receipt Number: a5_-uat-16 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: ro`k•CiCL.sCAI-40V\ 1' '•-- Phone: ( cc.)510- TJci Mailing Address of Applicant: Po 6 Vx. Z co(c) C� City State: L.JN Zip: 1 S SZ"S 12-digit Tax Parcel Number: 2--1--1-1 7- -5 - ael3O9 Site Address: Cl � \ G e t i \\C• L Permit Number: SWG �--�-` CO 41 PART 2: EXPLAIN WHY YOU NEED AN EXTENSION 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. r / Stamp: �'nt �O a�2S'2�S ��• 510.349 •��?r�i Signature of Designer/Engineer Date r ' PAULA JOY JOHNSON EXPIRES Comments/Conditions: PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only) ❑ Extension Denied 3 x Extension Approved New Expiration Date: ( / 10 Comments: P Environmental He Specialist Signature: ViEb 41430 AUG 9 Nc0,417,, 2025 This form m be scanned and available for public view on the Mason County°Yr AZ HFgI ty Page 2 of 2