HomeMy WebLinkAboutSWG2023-00011 APPLICATION FOR EXTENSION - SWG Application - 1/18/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
ea: 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: SWG2023-00011
APPLICANT DAVID KOBERSTEIN Phone:
Address: 8815 71st Ave NW GIG HARBOR, WA 98332
SEPTIC DESIGNER PAULA JOHNSON* Phone: 360-898-2255
Address: 171 E VUECREST DRIVE UNION,WA 98592
SEPTIC INSTALLER SHUMAKER CONSTRUCTION Phone: 360-377-2425
Address: PO BOX 3378 BELFAIR, WA 98528
Site Address: XXXX NE Tahuya Blacksmith Rd
Primary Parcel Number: 223305000205
Permit Description: New SFR -2BR Pressure with permit expiration extension
Permit Submitted Date: 01/18/2023
Permit Issued Date: 02/03/2023
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $945.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 01/23/2028 (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.
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/environmentallonsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
M .:. MASON COUNTY 415 N 6TH SHELTREE TO-427-9670 A 98584
T. 400
Public Health & Human Services BELFAIR:360-275-4467, EXT.400
i
OPi
PLICATION FOR EXTENSION
\ p�C 26 ,-� Amount Paid: 6 16
\N Receipt Number: a01. 0 587
1 ��
Instr�i Lions scant to complete Parts 1 and 2 and septic designer/engineer to complete
Part 3Y;emit 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: QP\V t17 le-ND8eR51 EI NI Phone: (25. )2.25- D025"
Mailing Address of Applicant:E 1S —1 t ST "J l•Ilk\
& `
City: 0 IG. H-'R
State: \IA Zip: Cif332
12-digit Tax Parcel Number: 22 3 3 0— Sb-- 2.os
Site Address: I'?) XX N E. —T;4HU lq a KSH ITN RD)TA-t+vTf) c.OA e3SS$3
Permit Number: SWG 20 Z 3—t"00 I I
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
2P i NI FIFO 15 1NS l /IL1 FD . NEED F10gE TrM TO
1 IQ S TAL L Trq tJK S
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/Eear Stamp:
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pr,`•. t 1 1
Signature of Designer/Engineer Date ;t 4).i
','4 PAULA JOY JOHNSON .
uct ,s btgai�t�
EXPIRESWir;
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Comments/Conditions:
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
0 Extension Denied Q
Extension Approved New Expiration Date: 0 ` / 13/?o Z"
Comments: l
Environs - tat Health Specialist Signature: 4,45:0,, !/ UFC?
Z/Z 4 "l"F 94a.
is form may be scanned and available for public 044;i*the Mason County Web site.
4,44,`kr,. Page 2 of 2