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Home My WebLink AboutSWG2025-003854 - SWG Application / Design - 7/1/2022 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 �' BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA: 360-482-5269, EXT 400 FAX:360-427-7787 On-Site Sewage System Permit: SWG2022-00384 APPLICANT ROSE THOMAS J & LINDA K Phone: 1.360.470.8935 Address: 905 GARDEN HILL RD W ELMA, WA 98541 OWNER ROSE THOMAS J & LINDA K Phone: 1.360.470.8935 Address: 905 GARDEN HILL RD W ELMA, WA 98541 SEPTIC DESIGNER JUSTIN RUSSELL* Phone: 360.956.7242 Address: PO BOX 14531 TUMWATER, WA 98511 Site Address: 1190 E MANZANITA DR Primary Parcel Number: 321045600039 Permit Description: New two bdrm- Nuwater shallow trench Permit Submitted Date: 07/01/2022 Permit Issued Date: 07/21/2022 Issued By: Luke Cencula Current Permit Fees Paid: $665.00 (additional fees may be required upon installation of system). Permit Expiration Date: 07/14/2027 (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 (12') and downslope (10') 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. 7 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is obtained 8 Gravel-less chambers required per design. 9 Transport line must be sleeved under any driveways. 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. ff.: MASON COUNTY 415 N 6111 STREET,SHELTON WA 98584 SHELTON:360-427-9670, EXT.400 -�r-- Public Health & Human Services BELFAIR:360-275-4467, EXT.400 APPLICATION FOR EXTENSION l/VECE. 1 FE Amount Paid: it I ( ._----_ DEC 0 Receipt Number:)_0a6 6510 3 �025 By Instructions: Applicant to complete Parts 1 and 2 and septic designer/engine Part 3. Submit application with extension permit fee. Make check payable to Mason Coun 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: o 0-c_ jZ Phone: 36.0 t{7C) $`t `i Mailing Address of Applicant: jd c 6 c., 1,,III v J 'i,t) City: e 1._ State: 1-4-) A- zip: �1C3' L) • 12-digit Tax Parcel Number: 3 11 O - S 6 - O n '3 Site Address: Permit Number: SWG U L2 00 7Qp 9 PART 2: EXPLAIN WHY YOU NEED AN EXTENSION Co ems-- U i l i 1-06 This form may be scanned and available for public view on the Mason County Web site. Page 1 of 2 O xogdow4110 - 0 sieAe aZ qAH .. AllVS ' N.D1211Vd - . 'NV3331S W NV('8 3NNVflO1 3 531AIVf '1V 13 "1Sfl2il 2J3llfl3 1�11UVV3 l/ay, W s 01V2139Z113 N VaNII '8 I SVWOHI sof '3SO2J 11321 Dll S3WOH 3N13 8V V N32JVN 1V 13 QN3W(1V a 3INVl3W '8 a 1301 '3111V38 11 OH 8V 3 3NId3H1VN '8 3 12138O J 'laNV2J8 Z , 3S02i . AQN3M 'GNII 31173 1 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/En:ineer Stamp: % `. r,Q l e I rrP ,i'e'+, • Signature of Designer/Engineer Date �,sr , '`,' ' �b I . i 22030834 +1 i MILPO.P.M4L f r I • tSI NCR I Comments/Conditions: pva y c,,, .e},r,`„-ez d.ori// 1/1.6,4 ,r AS ey�1,..4,. — imarameminameamme PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only) ❑ Extension Denied Extension Approved New Expiration Date: Ir l 7 .� omments: Environmental Health Specialist Signature: (Z)1WilVitLf(C(11 l Z)LI I2� This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 I f