HomeMy WebLinkAboutSWG2022-00014 - SWG Application - 8/8/2026 STREET.SHELTON WA 98584
MASON COUNTY 415 NSHELTON:360-427-9670, EXT.400
aELFAIR: 360-2754467.EXT.400
Public Health & Human Services
APPLICATION FOR EXTENSION Thr1W ( 4f1111`
Amount Paid: l________ OCT 02 2026
Receipt Number: 1-1P- 0q N iol I p p c
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
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Name of Applicant: C 1 aS s �n [.1d5 Phone
Mailing Address of Applicant: (Onnn15 RA
city: nO hi7MisI
state: Lila Zip: 98�°I0
12-digit Tax Parcel Number: 2 ao al 59 o/o9 a i
Site Address: Si 1E T ni D2c P\
Permit Number: SWG oao4'a QnO i4
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 WAG 246-272A.
IDesigner/Engineer Stamp:
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gnature of Designer/Engineer Date I oo,E1
tCFrv5 0E9i0xER
IE%PIPES 111161
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Comments/Conditions:
PART 4: HEALTH DEPARTMENT DETERMINATION (staff use only)
❑ Extension Denied O' ( Zn /�7�
Extension Approved New Expiration���
Comments: Qn
Environrrppeefl�I Health Specialist Signature: MgSOpC✓L1h 0CT 057026
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This form may be scanned and available for public view on the CMieOrr
Pag.2 of 2
415 N 6TH STREET,SHELTON,WA 98584
MASON COUNTY $BECTON:360427-9670,EXT 400
BELFAIR:360-2754467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT400
FAX:360427-7787
On-Site Sewage System Permit: SWG2022-00014
APPLICANT SHIELDS JAMES&NANCY L Phone:
Address: 1820 CONNORS RD SNOHOMISH,WA 98290
Email:
OWNER SHIELDS JAMES&NANCY L Phone:
Address: 1820 CONNORS RD SNOHOMISH,WA 98290
Email:
SEPTIC DESIGNER ROD LEFT-Acme Design Phone: 360-698-8488
Address: PO Box 2954 SILVERDALE,WA 98383
Email: info@acmeseptc.com
Site Address: 31 E JUNIPER PL
Primary Parcel Number: 320215901021
Permit Description: New SFR-3BR Pressure with permit expiration extension
Permit Submitted Date: 0111912022
Permit Issued Date: 0810812022
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $670.00 Iaaaivoaal reel may be reaa.oa upon installation or system).
Permit Expiration Date: 0112812027 leased on date of inspeclio^I
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 Drain field 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: masoncountyw36 ovThe 670 or call:
extensbnn400.nitsloss-inspection-request.php