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Home My WebLink AboutSWG2023-00240-APPLICATION FOR EXTENSION - SWG Application - 6/25/2026 • M AS O N CO U N TY 415 N 6TH STREET,SHELTON WA 98584 SHELTON:360-427-9670,EXT.400 Public Health & Human Services BELFAIR:360-275-4467, EXT.400 ,.7 P APPLICATION FOR EXTENSION �l Amount Paid: j Lj JUN 252026 Receipt Number: - y 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: Mark Buntin Phone: 805.403.1844 Mailing Address of Applicant: 4311 Carpinteria Ave City: Carpinteria State: CA Zip: 93013 12-digit Tax Parcel Number: 322247590120 Site Address: 484 Hurd Rd, Belfair, WA 98528 Permit Number: SWG 2023-00240 PART 2: EXPLAIN WHY YOU NEED AN EXTENSION Delays with the additional info request for geotech report. 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. IDesigner/Engineer Stamp: 06.25.2026 I Signature of Designer/Engineer Date 21037126 crRICHARD L BAZZELL LICENSEDT)FSIGNER Comments/Conditions: — PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only) ❑ Extension Denied Extension Approved New Expiration Date: (7_1 f 7/�U Comments: c9 cke 1 IZ *cu + prL R4e Environmental Health Specialist Signature: /i- This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2