HomeMy WebLinkAboutSWG2022-00165 APPLICATION FOR EXTENSION - SWG Application - 3/12/2022 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
A BELFAIR:360-2754467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
..1� FAX:360-427-7787
On-Site Sewage System Permit: SWG2022-00165
APPLICANT CHRIS AUSETH Phone:
Address: PO Box 2192 SHELTON, WA 98584
APPLICANT KEITH FULLER Phone:
Address: 123 XXX XX, XX. 00000
OWNER STOUT ET AL NATHAN E Phone:
Address: KEITH D & KATHRYN FULLER SHELTON, WA 98584
SEPTIC DESIGNER MICAH HALVERSON* Phone: 360-490-6365
Address: PO BOX 1519 SHELTON,WA 98584
SEPTIC INSTALLER JAMES MEDCALF* Phone: 360-426-9277
Address: PO BOX 1552 SHELTON, WA 98584
Site Address: 21 SE Neiland Ct W
Primary Parcel Number: 320323290064
Permit Description: New SFR -3BR Nuwater with permit extension
Permit Submitted Date: 03/31/2022
Permit Issued Date: 04/21/2022
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $935.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 04/08/2027 (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: masoncountywa.gov/health/environmental/onsite/oss-inspection-request.php or call:
360-427-9670, extension 400.
J L MASON COUNTY 415 N 6T"STREET, SHELTON WA 98584
SHELTON: 360-427-9670, EXT.400
`.� Public Health & Human Services BELFAIR: 360 275 4467, EXT.400
APPLICATION FOR EXTENSION p , :� t
Amount Paid: # '.P SEP 0 5 2025
Receipt Number: g-O,j 'MOO
By
Instructions: Applicant to complete Parts 1 and 2 and septic designer/en ' er 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: stv 5 t Phone:
Mailing Address of Applicant: p 0 2 I c Z
City: 51-k v, State: t-3 Zip: E.s' S
12-digit Tax Parcel Number: '3 ZO"32 - 3Z - c bU C L)
Site Address: 2 i 5 1,
Permit Number: SWG Z - C(`0 I
I
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
�L Zo &Ll - O i3q0
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/E •,ineer Stamp:
sr gr till
1
i
5- Zo zs ,�: ,�1:
1
Signature of Designer/Engineer Date 14
5100409 /ti
ANCAH11{ANi2L HALVERSON •
i• LICENSED DESIGNER 1,
EXPIRES.09/18/ j
Comments/Conditions:
.I 4-� 1I{r ' 5C.,,., Lk cciC-
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
0
0 Extension Denied
Extension Approved New Expiration Date: 0 ( / OR 7 Z
Comments: i�
Environ ntal Health Specialist Signature: SEP
MgSONcoUN,Y 9 1025
scanned and available forpublic view on�t'Ti® M a my Web site.
i form may be rN
Page 2 of 2
j
a