HomeMy WebLinkAboutSWG2022-00082 APPLICATION FOR EXTENSION - SWG Application - 10/6/2025 (2) 415 N 6TH STREET,SHELTON,WA 98584
rnt •-. MASON COUNTY SHELTON:360- -4467,EXT 400
BELFAIR:360-275275-4467,EXT 400
-..✓ i 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: 03/02/2022
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 Drain field 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.govlhealth/environmental/onsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
T. SHELTON WA
584
MASON COUNTY 415 NSHELTONE 60-427-9670 EXT84 0
BELFAIR: 360-275-4467. EXT.400
Public Health & Human Services _ __.
APPLICATION FOR EXTENSION LILI OCT 0 6 20Z5 libI
Amount Paid: S (D5 y
Receipt Number: 2oa-5-04g3o
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
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Phone: �'�" `l 4� �O6
Name of Applicant: �'t C- � �`—.\�,�� 5
Mailing Address of Applicant: S3?A V��o ' SE
City: 5 YW ko't'1c.-5h State: 'P` Zip: °
12-digit Tax Parcel Number: 2;1'33 0 — U O 33 Z `
Site Address: (,0 _U0 v� _ e_ ) ���� � ci SsM
Permit Number: SWG ?AZZ�— 000 gZ
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.
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PART 3: ORIGINAL DESIGNER/ENGINEER REVIEW AND APPROVAL
I, the undersigned original Designer/Engineer, att
date of my signature reinsp reinspected
belo the property and
found the following conditions to be true as ofthe
• 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.
Design�F:; 2r Stamp:
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510 349 .•t:..
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Signature of Designer/Engineer Date ..- ' PAULA JOY JOHNSON .y kn
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Comments/Conditions:
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied Extension Approved New Expiration Date: 0$/c I /(.f/ Z
Co 7,�mments:
Environmenta alth Specialist Signature: �lgsONc OCj ,7202
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This form may be scanned and available for public view on the Mason Comity sir .
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