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Home My WebLink AboutCRT2002-00061 - CRT Application - 5/6/2002 MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFMCE BOX 1666 SHELTON, WA 98584 (360)427-9670 PAX 42 7-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW ('}{ Receipt NO: ij S `� Date of Payment: Se or Water Review ($85) : ` }. MAY 0 2 Both ($100) : I - Property Evaluation ($85+$50/Hr) : - I HEALTH SERVICE` i Cl�l(�..t 9 INSTRUCTIONS V e�5 1. An application is considered complete when the fee is paid, Parts 1-4 of the application form are completed. (assistance will be provided upon request for completing Part Two), the necessary paperwork is attached, and required soil evaluation holes have been excavated. 2. After a completed application is received, staff will inspect the property and provide the applicant with a written report. - 3. if the site review requires more than 1 hour of work, the department will charge the applicant an additional hourly rate of S50/hour as set forth by the Mason County Board of Health. PART 1: APPLICANT/PARCEL ID NTIFICAI TION D NAME OF APPLICANT y0. J d k y '�t"+'2 /n, d�c�[:`I��.SE TELEPHONE (i1116) On SITE/HOUSE ADDRESS J /,�/.�r Y � `"� MNILING ADDRESS ACREAGE City '�yy State jJLip )) ASSESSOR'S PARCEL NUMBER Z SL - Z L— - 6 — A L� LEGAL PROPERTY DESCRIPTION •�� i' -L Y SUBDIVISION (If Applicable) 06 pi QAV i 3._ DIV BLK LOT DIRECTIONS FOR LOCATING SITE � eQ- yo rP ling e� P 1�� ' -Cl- Sketch location of property in this space. I I ,_—,� �✓C 4 i Vi �. sa. � I I I I I I I '701 �Z I N:\ON-SITE\ENREVIEW-W Revision 2126199 Page 1 PART 2: PURPOSE OF APPLICATION 2A. OPTION ONE I am applying for a bank loan and the bank has asked for an evaluation of the following: Septic System (Fee: $85) / • Age of System Age of House • Number of Bedrooms Name of Last Owner • Is house currently occupied? _ Yes No • Attach punper's report, dated within Last3 years, stating whether the system was pumped, the size and - condition of the tank, and the condition of the baffles. n LJ Water System (Fee: S85) Number of service connections on water system If public water system: Name of System n WFI Number U Both (Fee: $100) Provide information shown above for both septic and water systems 2B. OPTION TWO I—I tJ I am applying for a building permit and environmental health has required an evaluation of the following: r_1 LJ Existing Septic System (Fee: $85) • Age of System • Number of Bedrooms Name of Last Owner Is house currently occupied? Yes No Attach punper's report, dated within Last 3 years, stating whether the system was pumped, the size and condition of the tank, and the condition of the baffles. If the original septic permit cannot be located and system less than 5 years old, apply for new On-Site Sewage Disposal Permit. If the original septic permit cannot be located and system more than 5 years old, submit signed as-buiLt drawing from certified designer or professional engineer. - r—I L-J Reserve Area for Future System Repair (Fee: E85) Two properly excavated pits are 4 ft deep must be ready for inspection by the department. n LJ Both (Fee: S85) • Provide information shown above for both septic system and reserve area H:\ON-SITE\EHREVZ .W Revision 2126199 Rage 2 2C. OPTION TMEE LJ I am interested in ]mooring in general terms the suitability of a parcel for septic system placement. (Fee: $85 base, plus $50/hour after first hour) Describe the intended use of the property and the reason for requesting the review: 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. - i I I I I I I I I I I I I I I I I J� I I I I I I � I I /e"` I _ I I � I I � I I � I I I I I I I I I I I I I I I I T�S I l I I I I PART 4: AUT TION APPLI DATE `l N:\ON-SITE\ENREVIEW-W Revision 2126199 Page 3 PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY SA. DETERMINATION OF APPLICABLE STANDARDS The primary drainfield area must meet the following standards: n n u Meet current standards U Standard marine system n No overt failure U Not applicable. The reserve drainfield area must have site characteristics that could support a septic system that would meet the following standards: n n U Meet current standards. U Meet marine repair standards. n L_I Meet marine expansion standards. Not applicable. 5B. WATER SYSTEM YES NO INDIVIDUAL WATER SYSTEM n n LJ u A water sample was taken by health department staff and analyzed. Total coliform bacteria were determi to be absent. Laboratory results are attached to this report. n n U U The well cap w inspected. The sanitary seal appears satisfactory. n n U L_I The well casing was • spected. The casing pr )ected above ground and ground was sloped away from the casing. n n U U The well site was inspected. s is systems, chemical storage facilities, manure piles, animal feed lots, or other obvious sources o ontamination were located within a 100 foot radius of the well. PU IC WATER SYS n n U U Records indicate wat sampling requirements ar being satisfied. n n U U Records indicat the Water facility Inventory form is current. n n LJ U Department iles contain water system design and letter of approval? 5C. SEPTIC SYST YES NO Xn U The septic tank was inspected by a certified septic tank pnper within the past 3 years and found to be in satisfactory condition. A punper's evaluation is attached to this report. n U Records for this property contain a septic permit, design (if required), final inspection approval, and as-built approval. `SQ-L Pok Un �4s'� PA`V- l� n U The drainfield site was inspected, and appears consistent with recorded documents. n U The drainfield area appears to be maintained in an acceptable manner. r� n X� U The drai of field area (the area where the drainfield is assumed to be located based on office records and/or observed site conditins) appears to be maintained in an acceptable manner. n U The drainfield area (the area where the drainfield is assumed to be located based on office records and/or observed site conditons) show no indication of overt failure at the time of inspection. H:\ON-SITE\EHREVIEW.W Revision 2126/99 Page 4 5D. SOIL CONDITIONS TEST HOLE #1 I TEST HOLE #2 I TEST HOLE #3 I I I I I I I I I I I i � i I I I I I I I j j I I Depth to re r. layer I Depth to rest layer I Depth to restr. layer I I Soil Type: I Soil Type: I Soil Type: I I I I I FINDING SCORE I I I Soil Typ I Soil Depth: I I Slope: I I Parcel S'ze: I I Distan a to Shoreline I I I SE. OTHER NOTES AND OMMENTS H:\ON-SITE\MH IEW.W Revision 2126199 Page 5 PART 6: HEALTH DEPARTMENT DETERD [INATION - OFFICIAL USE ONLY 6A. PRIMARY DRAINFIELD SYSTEM The primary drainfield area was inspected by staff and pertinent records were reviewed. The following determination was made: n The system appeared to be functioning adequately at the time of inspection and and meets current design standards. I The system appeared to be functioning adequately at the time of inspection. I—I Not applicable. Continents: 7y2 S24� m041 fb COAr, / _ ✓hwm 6"p40,14 v1s uH¢wr � . 6B. RESERVE DRAINFIELD AREA The reserve drainfield area was inspected by staff and the soil was evaluated. Site characteristics indicated an area exists that could support a septic system that would meet the following standards: n IJ Current standards. I—I - U Marine expansion standards. I-1 u Marine repair standards, Treatment Standard Not applicable. Comments: Ai O9 S 6C. {PATER SYSTEM The water s tem was evaluated by staff and the following rmination was made: n U The water so ce consists of an individual 1 that appears to be a satisfactory so a of potable water a single family residence. The water was sampled, and co orm bacter' ere found to be absent. n U The water source is a p c wa system that appears to be in substantial compliance with appl ' le regulation . Comments: .............................................................................................................................................................................. findings and determinations of this review reflect observed conditions as they existed on the day the evaluation was performed. Absolutely no claim is made by this office, either expressed or implied, concerning future success or failure of the systems and sites evaluated. Resource land and critical area checklist may be required by Department of Community Development prior to issuance of developmental permit. INSPECTOR ,��`�a— IPA""A"" 1.'4A4 DATE S I1 I OZ H:\ON-SITE\EHREVIEW.W Revision 2126199 Page 6 -.(7lN4� �_FJjrrP O?Q i Uj�[ L I 1 G j , j I i or, i