HomeMy WebLinkAboutSWG2021-00587 APPLICATION FOR EXTENSION - SWG Application - 10/25/2021 MASON COUNTY 415 N 6TH STREET,SWA 98584
SHE SHELTON,
42 TON, ,EXT 400
584
BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT400
FAX:360-427-7787
On-Site Sewage System Permit: SWG2021-00587
APPLICANT Debi Hansen Phone:
Address: 15217 103rd Ave NE BOTHELL, WA 98011
OWNER McCormick, Ross Phone: 5309238613
Address: 20 NE Pond CT Belfair, WA 98528
SEPTIC DESIGNER JIM HUNTER* Phone: 360-753-1226
Address: PO BOX 162 OLYMPIA, WA 98507
Site Address: 20 NE POND CT
Primary Parcel Number: 223107500080
Permit Description: New SFR -3BR Nuwater
Permit Submitted Date: 10/25/2021
Permit Issued Date: 11/23/2021
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $640.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 11/17/2026 (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.
T, SHELTON WA 98584
J ` MASON COUNTY 415 NSHELTONE 60-427-96 0 EXT. 400
--r' Public Health & Human Services BELFAIR: 360-275-4467, EXT. 400
APPLICATION FOR EXTENSION
Amount Paid: it I (p6
Receipt Number: 84Ti — DEC 3 0�_i .; 2025
Instructions: Applicant to complete Parts 1 and 2 and septic designer/engine*to c
Part 3. Submit application with extension permit fee. Make check payable to Mason --�
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: Ross McCormick Phone: 530 923 8613
Mailing Address of Applicant: 20 NE Pond CT
City: Belfair State: WA Zip: 98528
12-digit Tax Parcel Number: 22310-75-00080
Site Address: 20 NE Pond CT Belfair WA 98528
Permit Number: SWG 2021-00587
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
Original septic desgin completed by previous property owner. I was unable to build system
before original expiration date due to when I purchased the property.
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, 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:
12/30/25 012/30/25
Signature of Designer/Engineer Date u ''
a_wU
11pRL1J NUVTEF
Comments/Conditions:
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied
)if.. Extension Approved New Expiration Date: l l Z O
Comments:
Environmental Health Specialist Signature:
This form may be scanrd and available for public view on the Mason County Web site.
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