HomeMy WebLinkAboutSWG2022-00358 APPLICATION FOR EXTENSION - SWG Application - 3/30/2026 MASO N COUNTY 415 N 6TH STREET,SHELTON WA 98584
SHELTON:360-427-9670, EXT.400
Public Health & Human Services BELFAIR:360-275-4467, EXT.400
APPLICATION FOR EXTENSION
Amount Paid: I
Receipt Number: _ O l
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
Name of Applicant: $.r6VI o J J e.rC IR14 e- Phone: q Ag - be t — ) -i RS
Mailing Address of Applicant: a2% W\ -5c' ' 1Jt -r—
City: 6 ,P -v ; e 0 State: IA) o*..- Zip: 1 BS'l
12-digit Tax Parcel Number: oZa 1 ® — -t 3 —
Site Address: (O 1\ E , 3-c s- ' Q-Knn
Permit Number: SWG oZip Z Z - O D 3S�P
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
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.
IDesigner/Engineer Stamp:
I I
OF WASH•
Signature of Designer/Engineer Date
_' ROBERT H379AYSSE'
EXPIRES
I
Comments/Conditions: — — — — — — — —
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use on )
O Extension Denied
IExtension Approved New Expiration Date:
omments:
1J
Environm t I Health Specialist Signature:
LIJAI\ J
This r a e scanned and available for public view on the Mason County Web site.
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