HomeMy WebLinkAboutRe-Inspection - SWG Application R.. pl/�2/2010 TUE 16: 31 FAX 3604279442 MC ENVIRONMENTAL HEALTH 0002
MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SHELTON, WA 98584
(360) 427-9670
FAX 42 7-7798
A.PPLICA1'iON KiR Kl -1NSPE(:T1UN
- ON-SITE SEWAGE PROGRAM -
DIRECTIONS
1. Complete Part 1-3 and submit to the Director of Health Services. PO Box 1666. Shelton, WA 98584.
2. The on-site lead will make a determination in Part 4 whether a rc-inspection is justified. When a re-
inspection is made. the findings of the second Environmental Health Specialist are written in Part 5. A
I final determination by the lead is recorded in Part 6.
a
J. Applicants arc billed at the current adopted fee schedule Mien a re-inspection is required and are ex-
pected to pay for any necessary laboratory costs associated with soil tests. unless prior arrangements
are made With the health department.
4. findings and determinations of the lead may be appealed to the Hason County Health Officer at the ad-
dress listed above.
PART 1: REQUEST FOR RE-INSPECTION
Applicant's Name: e-CrLA
Address: 2,9 0 4-y` 4, ." 'z TIC
Telephone:
) essssr "s`Parrce `r b b l tSubdivision Name and Lotr
Health Department finding being disputed by applicant:
n n r-h
LJ Anticipated depth of vatertable u Soil type/application rate u Depth or presence of mottling
n / n
New dr
�nain�7'Q field area'i�evaluate '—' Other (please specify)
— A
PART 2: AUTHORIZATION
APPLICANT ICc1' DATE 1'3 lD
H:ON-SITE\RE-EVAL.W Revised 12/18/97
01/12/2010 TUB 16: 31 PAX 3604278442 NC ENVIRONMENTAL HEALTH 0003
PART 3: PLOT PLAN
Use this space to draw a detailed plot plan, or attach one to this application. A detailed plot plan is one that
shows the precise location of the test holes. existing septic systems. dimensions of the property. and location of any
wells. roads. or other buildings on the property.
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PART 4: DETERMINATION OF LEAD
El Re-inspection is justified.
Re-inspection is not justified. for the following reason(s) :
On-Site Lead Date
H:ON-SITE\RE-EVAL-Y Revised 09/03/96
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