HomeMy WebLinkAboutSWG2023-00406 APPLICATION FOR EXTENSIOIN - SWG Application - 8/27/2026 MASON COUNTY 415N6 STREiEToa LT VVAGEnao
Public Health & Human Services BELFAIR. 360-275-4467 EXT 400
APPLICATION FOR EXTENSION 1I
AUG 27 2026 !JI
Amount Paid: 17U
Receipt Number: ° j .(,Q 0 3 '75
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 QQ PARCEL INFORMATION
Name of Applicant: L) Ep t- 4,zry n Phone: 30- a1t - 00S5
Mailing Address of Applicant: •1 I E
City: State: l_ R" Zip:
12-digit Tax Parcel Number: 32 f O ' - 5_7 — QUO<(o
Site Address: 13l E y - t 1- "-'p\-t I^' tj y t- -
Permit Number: SWG 2°23 - CIO 'EO (o
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.
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.
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Signature of Designer/Engineer Date ' , anuu5dor�onusoe
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Comments/Conditions: — — — — — — — —�
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PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
O Extension Denied
Extension Approved New Expiration Date: V�l Z LOZ�
Comments:
Environm t alth Specialist Signature: `?
7 orm may be scanned and available for pdbrtg,vjew 6n fie Mason County Web site.
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