HomeMy WebLinkAboutSWG2023-00106-APPLICATION FOR EXTENSION - SWG Application - 8/24/2026 MASON COUNTY "SN6THELTON , 0427-9 70 EXT 400
SHELTON.IIW 360- 7,EXT 400
BELFAIR:360-275-4462754467.EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX'.360-427-7787
On-Site Sewage System Permit: SWG2023-00106
APPLICANT DUMONTET DONALD H Phone: 360-462-0155
Address: 3610 DAYTON-AIRPORT RD SHELTON,WA 98584-8947
OWNER DUMONTET DONALD H Phone: 360-462-0155
Address: 3610 DAYTON-AIRPORT RD SHELTON, WA 98584-8947
SEPTIC DESIGNER CINDY WAITE` Phone: 360-701-0205
Address: 80 E PICKERING LANE SHELTON, WA 98584
Site Address: 4282 W Dayton Airport Rd
Primary Parcel Number: 420083000000
Permit Description: New SFR-3BR Gravity Bed
Permit Submitted Date: 03/20/2023
Permit Issued Date: 07/12/2023
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $695.00 (additional fees may be required uponmstauanonotsystem)-
Permit Expiration Date: 03121/2028 foaled on date ormspeonon)
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 055.
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/onsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
MASONCOUNTY 415 NSHE TON:360-427.660 EXT.400
Public Health & Human Services aELFAIR:360-276-4467,EXT.400
°'. APPLICATION FOR EXTENSION
il�l 1110
Amount Paid: ISO
4 Receipt Number: a.ba-Ca- 03 `J
Insiructions: 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 ofApplicantTNdlt) Domonicl Phone: 3n- 2r�, fl /
Mailing Address of Applicant: -76 r0 D�.� N �;rr.r,
City: S71e II4tN State: La. Zip:
12-digit Tax Parcel Number: !/2 O68'—3a - 6 Cl 66f
Site Address: 't'2f2_ lv 1�.,,i=. ," (i=n f- Rol
Permit Number: SWG 2n d ..Oo cot
PART 2: EXPLAIN WHY YOU NEED AN EXTENSION
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This form may be scanned and available 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:
• 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.
Signat rueDesigner/Engineer Date I \y�
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LICENSED f�ESIGNER
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Comments/Conditions:
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PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑n Extension Denied
fomExtension Approved New Expiration Date: 311 J
ments:
Environmental Health Specialist Signature:
8(2-1I7
This form may be scanned and available for public view on the Mason County Web site.
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