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HomeMy WebLinkAboutSWG2022-00082 APPLICATION FOR EXTENSION - SWG Application - 10/6/2025 415 N 6TH STREET,SHELTON,WA 98584 J` ; MASON COUNTY SHELTON:360-427- ,EXT 400 BELFAIR:360-275-44674467,EXT 400 . Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 On-Site Sewage System Permit: SWG2022-00082 --> APPLICANT ALDER CREEK CUSTOM HOMES LLC Phone: 1.425.232.1118 Address: 5320 138TH DR SE SNOHOMISH, WA 98290 OWNER ALDER CREEK CUSTOM HOMES LLC Phone: 1.425.232.1118 Address: 5320 138TH DR SE SNOHOMISH, WA 98290 SEPTIC DESIGNER PAULA JOHNSON* Phone: 360-898-2255 Address: 171 E VUECREST DRIVE UNION, WA 98592 SEWAGE INSTALLER RICHARD MOORE* Phone: 360-509-1342-Rich Address: PO BOX 963 BELFAIR, WA 98528 Site Address: 680 NE Haven Lake Dr Primary Parcel Number: 223305000332 Permit Description: New four bdrm-Nuwater trench with permit extension Permit Submitted Date: 02/24/2022 Permit Issued Date: 03/0212022 Issued By: Luke Cencula Current Permit Fees Paid: $665.00 (additional fees may be required upon installation of system). Permit Expiration Date: 03/01/2027 (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 Drainfield installation not to exceed designed upslope and downslope depth specified on design form. Follow excavation depths exactly per design. 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 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is obtained 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. IVIASOCOU NTY 415 NSHELTONE 60-427-9670 EXT.400 . . BH STREET, T, SHE TON EXT.VVA 584 ..--1 400 re,�� '� ;�' Public Health & Human Services __.__y_ ; r fit APPLICATION FOR EXTENSION !.1 OCT 6 202� !;�' Amount Paid: _111 ' Receipt Number: ' 3�'O L4ct 30 Instructions: Applicant to complete Parts 1 and 2 and septic designer/engi neer Mason to complete Part 3. Submit application with extension permit fee. Make check payable unty 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 r-c''�� "r:V`---1�0i_ Name of Applicant: C Phone: (e" - 21 \ 4 2-tO?, Mailing Address of Applicant: 6-3e, W SE City: 5 No ko h^^ 5 h State: Wes Zip: 12-digit Tax Parcel Number: Z 23 © - SD- 0033Z Site Address: (.0�0 !v e } Ve'`^ I.-a-lam - ) -t-°-)v-" "k`\. l-)-- 9 s5c8 Permit Number: SWG Z,C2_2r— 000 g2— PART 2: EXPLAIN WHY YOU NEED AN EXTENSION Asa t„) a-'s 5 0 L9,. N-ei,) 0 (.,. - %,,g -s v � - ---„,...Q c 4 )-e�.c)f A- cis} -1.- `k--;-o-- 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. l'ieSir'n•.19Cr.•' er Stamp:s� ,Z.QievL___ La " 2 - S • **1. ir J 510r,3;9 ••t�i1 ) Signature of Designer/Engineer Date' PAUU JoV JOHNSON :7".S ! kec4M.S.alin;_516iVe• ‘1 ri Ca -3-2.5 Comments/Conditions: PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only) E Extension Denied 7 Extension Approved New Expiration Date: 03! I / Z Comments N;. k Environmenta alth Specialist Signature: %� �' b 04, (V /" 7/�U GS ,v,, jR )5 This form may be scanned and available for public view on the Mason Cour{jN gite. 4/71 rti Page 2 of 2