HomeMy WebLinkAboutBLD2010-00548 - BLD CD Environmental Health Review - 6/29/2010 COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
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415 N. 6th Street Permit Number: Lx v�l�vlJ �l�
PO Box 1666
Shelton, WA 98584 Date Received: (.F�da��7 U
Shelton: (360) 427-9670, Ext. 400 Amount Received 6� o
Belfair: (360) 275-4467 Ext. 400
Elma: (360)482-5269 Ext. 400 Receipt Number /v_ (rcrCO
Fax (360) 427-8442
Applicant Information Type of Review
Applicant( k/� t A yA Dat L5' Buildi Permit
g l-% lrJA �� New 0 Replacement
Mailing Address��,
0 Commercial Building Permit
City ��,, State Zip 0 New Ell Replacement
Daytime Phon /Other Phon 2_n 0 Building/Commercial Permit Revision
/ O Tenant Review
E-Mail Address p �? zi,N�/� S y �C'O//'/ p Pre-Application
Parcel Information
12-Digit Parcel Number �������� ✓ �����
Site Address 3Q C. G-4 a-x
Street Number Str et Name r City
Type of Job Please submit a scaled plot plan
Describe work </Vt-2x ) showing all existing and proposed
Number of Bedrooms building, on-site sewage system,
and well.
On-Site Sewage Information Water System Information
O On-Site Septic System 0 New m: Existing Plumbing in structure? O Yes 0 No
0 Sewer Name of Sewer System If yes:
Using an existing on-site septic system will require a current Please submit a completed Water
maintenance report and a Record Drawing (Asbuilt). Documents Adequacy Form.
for both of these requirements may be on file with Mason
County Public Health. Other requirements may apply.
App ' , nt Sig bure
Date
Official use only
Departmental Review Approved Denied Notes
Water Adequacy G �2_L'i -7" )? 10
On-site Sewage System J
Tenant Review
Revision
Revised 12/17/09
MASON COUNTY
DEPARTMENT OF HEALTH SERVICES _
- P rsonal Health
Environmental Health
PO BOX 1666$HELTON, WA 98584
L�FAX
CAL(360)427-9670
BEFAIR(360)275-"67
Application for Determination of Adequacy (360)427-7798
Instructions , .,7
11; Corer pan No deteibtl iti t r fd u
2 Cor» lete only the portion of Pact 2 ; to the type Sfh�+
3': nt mit ao d rt NGation,with..., tlts to the: .tft —264MML
PART 1: Applicant/Parcel Identification �,J O
Name of Applicant�IJ �� �y Da
_ s �L7L /
Mailing Address L Telep ones
Assessor's Parcel Number 9�
T e of Water System Check One): eas n for A lication Check e :
❑ Public/Community Water System(2 or more Building permit
co ectlons)" Land use application, if so..
ndividual water source(one connection), ❑ Division of land:
if so..
W #of Parcels? SPL_
Spring/surtace water ❑ Boundary line adjustment
❑ Other(explain) ❑ O er(explain)
•"If you have more than one residence placement(please indicate name of watel system
connected to this well,check the Public box. below if applicable-no signature required)
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Public Water System
Name of Water System
Water Facility Inventory (WFI) Number:
(write "none for two party)
❑ I am the manager of this water system.The water system has been approved for s ices.
There are presently connection(s)in use. This will be the connection.
❑ I am the manager of this system.This connection will be to up ade or change the use ol an
existing connection on this system(ie: recreational to full timef Please indicate on the f Rowing
line the nature of this change:
This water system is able and willing to provide water to this(these)connection(s)with ut
exceeding the limits of the water system or any limits set by state and local regulation.
I
Signature of Water System Manager Date —
u :April 2006
Individual Water Well
Fand
er well report(attach to application) Depth ft.
l capacity test(attach to application) gpm apd
we n ero en performs we capacitytests a e �me ewe is constructed. Results
these tests are noted on the water well report. Results from these tests will be
pted. if the water well re ort cannot be located by the applicant orif the water well report
s not have a capacity test a well capacity test, which provides stabilization of draw-down
recove data must be erformed b a licensed contractor.
Satisfactory bacteriological test(attach to application)
Individual S rin /Surface Water
F-I
rmit (attach to application)
disinfection
n to believe that this water source can provide at least 800 gallons per day and/or
er at a rate of 2 gallons per minute based on the following observations.
AUTHOR OF STATEMENT DATE
RELATIONSHIP TO APPLICANT
IN ADDITION TO PROVIDING THE ABOVE STATEMENT,THE APPLICANT WILL NEED TO ARRANGE AN ON-SITE
INSPECTION BY THE HEALTH DEPARTMENT PRIOR TO DETERMINATION OF ADEQUACY.
Departmental use only. Do not write below this line.
FART S''Health Department Evatuation{Staff Use Ont.W
SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to
meet the needs of its:intended use.
This determination
. guawtoe
an,adegvatesuAp1Y i
ctI via tBrtde�`inttel its the,fttUrp, orarntee c„rripfrarai e
With all apptica6le,4 !q Wdtertesoift it tts
UNSATISFACTORY DIETER MINATION Apoilcantsuuatar,s-up y ftk,hotappe r
adequate to meet hbeds-ofit irttet filed face"forte e.ft3tl ittt se lf'(s .,
REVIEWER'S SIGNATURE _ DATE
Update:April 2006
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