HomeMy WebLinkAboutSWG2022-00426 APPLICATION FOR EXTENSION - SWG Application - 7/29/2022 ( A MASON COUNTY 415 N 6TH STREET,SHELT967 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: SWG2022-00426
APPLICANT BALLOWE JAMBA S & KEVIN D Phone: 360-301-9173
Address: 21 SE SHADOWOD BLVD SHELTON, WA 98584-9336
OWNER BALLOWE JAMBA S & KEVIN D Phone: 360-301-9173
Address: 21 SE SHADOWOD BLVD SHELTON, WA 98584-9336
SEPTIC DESIGNER PAULA JOHNSON* Phone: 360-898-2255
Address: 171 E VUECREST DRIVE UNION, WA 98592
SEPTIC INSTALLER SHANE MAPLES* Phone: 360-463-8474
Address: 911 SE Arcadia Road SHELTON, WA 98584
Site Address: 51 SE Lagoon Ln
Primary Parcel Number: 320255000007
Permit Description: New five bdrm-shallow pressure trench with expiration extension
Permit Submitted Date: 07/29/2022
Permit Issued Date: 08/11/2022
Issued By: Luke Cencula
Current Permit Fees Paid: $945.00 (additional fees may be required upon installation of system).
Permit Expiration Date: (, 08/04/2027 (based on date of inspection)
Permit Conditions:
I 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(9') and downslope(7')depth
specified on design form. Minimum 6"appropriate cover material required.
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.gov/health/environmental/onsite/oss-inspection-request.php or call:
360-427-9670, extension 400.
MASON N OU COUNTY 415 N 6T'H STREET, SHELTON WA 98584
SHELTON: 360-427-9670, EXT.400
"y BELFAIR:360-275-4467, EXT.400
public Health Human Services
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Amount Paid: I`lO � f
Receipt Number: oL (� -Oa 7(� I
instructions: Applicant to complete Parts I and 2 and septic designer/engineer₹o 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 ₹o 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: \& t J 3PcLLO UVA Phone: ( o) 1 q,-13
Mailing Address of Applicant: S-S SE
City: State: 1A9 Zip:
12-digit Tax Parcel Number: 50 r U OOO' T
Site Address: 5 1 S LP6c, 4 I-- LTAk.
Permit Number: SWG 2D22— C 0426
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
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This form may be scanned and availlab➢e for public view on the Mason County Web site.
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PART 3: ORIGINAL DESIGNERIENGINEER 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:
e 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.
o 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.
Decigne./Ens rSiafllp:
Signature of Designer/Engineer Date ,ti ty
Y i^
fah' P ULA JOY JOHNSON
Comments/Conditions:
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
0 Extension Denied (Zo?7
Eension Approved New Expiration Date:
Comments:
Envir ental Health Specialist Signature:
MAso�r C 2 4 2026
has form may be scanned and available for paasilac view a�, e �ö r� Pflh,fl tY Web site.
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