HomeMy WebLinkAboutSWG2020-00321 INACTIVE CAN NOT EXTEND - SWG Inactive - 9/9/2025 enill, MASON CO U N Y 415 N 6711 STREET, SHELTON WA 98584
SHELTON: 360-427-9670, EXT.400
Public Health & Human Se Ices BELFAIR:360-275-4467,EXT.400
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!' pg3r11-3 APPLICATION FO EXTENSION
l:1 SEP092025 I.
Amount Paid:
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B Receipt Number: 9.oa5 -6w 4--
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Instructions: Applicant to complete Parts 1 and 2 nd septic c
Part 3. Submit application with extension permit fee Make the .k' 4-
Treasurer. Staff will review your application and de ermine if th `,U" A
Conditions for approval are outlined in this application. `
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Prior to or after expiration of an approved design, the applicant �, ,( .
extension. The permit extension shall extend the expiration of ti / �}'
but not exceed five years from the signature date of the Enviror C9 �, /
site inspection{Per WAC 246-272A-200(4)(e)} (O �Q/
All approved septic designs may receive one extension. Additio pv �•i`
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accepted and would instead require a renewal. \�
PART 1: APPLICANT AND PARCEL INFORMATI N
Phone: 3�6 -�2" - (�37
Name of Applicant: I /m i f/ Y z o 6
Mailing Address of Applicant: pc, .8 O X
City: -c4 M G A= State: \4-1,4 Zip: 5�3C> C
12-digit Tax Parcel Number: 3 Z 0 L / — S3.--- O G- 0 /Sf
Site Address: / S // (''J v 0_0 2' ' 5 /16 L / 6'
Permit Number: SWG Z v Z a — O 0 3 Z /
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
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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/Engineer Stamp:
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Signature of Designer/Engineer Date
Riovii E.WEAVER .,,'.
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Comments/Conditions:
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied
❑ Extension Approved New Expiration Date:
Comments:
Environmental Health Specialist Signature:
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2