HomeMy WebLinkAboutCRT04-00065 - CRT Application - 7/9/2004 L0JZ0d d [3g 3HMK IVIINHOnHd -01 0ZZ6-69L 09E WOHd TS:ST 60,-80 0 (DAI3)3r
DEPARTMENT OF HEALTH SERVICES
426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584 RF
SHELTON (360)427-9670 ELMA (360)482-5269 BELFAIR (360 275-4467 SEATTLE (206)4 -,Rf C E I V E D
WEB hyg:n xo.mason.wa.us FAX (360)427-7798
APPLICATION FOR ENVIROMENTAL HEALTH REVIEW 426 W. CEDAR STs
PERMIT NUMBER PAYMENT INFORMATION TYPE OF REVIEW
. ❑ Septic and Water $15
CRT Receipt Number ' ® Septic $100
❑ Cash ❑ Water $100
( Check oi?i)— -- ❑ Property Evaluation $100+$50 hr*
❑ Resample$50 hr+ lab fee
Date of Payment *After 1"hour
Important Notice: Findings &determinations of this review reflect observed conditions as they existed on the
day the evaluation was preformed. Absolutely no claim is made by this office, expressed or implied concerning
the future success, failure or permit approval of the system and site evaluated.
*** FILL OUT APPLICATION COMPLETELY AND ACCURATELY ***
An application is considered complete when the fee is paid,.parts 1, 2 and 3 of this application form are
completed, necessary paperwork is attached (i.e. pumpers report)and when required, soil evaluation holes have
been excavated.
PART 1: APPLICANT/ PARCEL IDENTIFICATION
Name of Applicant -r+00) j D kWV1 JAN DAlE, Telephone S 4 O-X71; -1 7 9
Mailing Address of Applicant 130 Al rz V40V7Z 44AQi,4 U
City AgLF411? State UJ4 , Zip �i f S21
12 Digit Tax Parcel No. O
Site Address l30 A/ F , 6,4At1_4 >«J.2/Ia LAI
Brief Legal Description 8jF42DS j!p a& O/P LOT` f
T
Driving Directions NOg)Wc. ,en Z—?M,0 T7 5j 0"/,c/— l Ziggstoga e,
0 94/729- /L1,4>9P/fJ . 64We oil/ 7P
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'PART 2: TYPE OF REVIEW
Q Septic System
• Age of System
• Age of House
■ Number of Bedrooms
■ Name of Last Owner ( 5QD !✓
• Is House Currently Occupied? ZYES QNO
• If not Occupied, how long has it been vacant?
❑Water System
• Number of Service Connections on the Water System
■ If a Public Water System, Name of System MAnoti eounrfy LrrIL/fLeS
■ WFI Number
❑ Property Evaluation (soil logs)
• Property evaluations provide, in general terms, the suitability of a parcel for septic system
placement. THIS DOES NOT GUARANTEE FUTURE SEPTIC SYSTEM APPROVAL
■ Describe the intended use of the property and the reason for requesting the review
PART 3: PLOT PLAN
Use the space below to draw a detailed plot plan, or attach a detail plot plan to this application. 7 he plot plan
should include the following: North Arrow, Precise Location of Test Holes, Location of Existing Septic System,
Dimensions of Property, Location of any Drinking Water Sources(wells, springs, etc...), Roads,Easements,
Surface Water, and Buildings on the Property.
g ir,
LOT SIZE
x
Acres
l '
CO PASS
Applicants Signature: Date:
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PART 4: HEALTH DEPARTMENT FINDINGS—OFFICIAL USE ONLY
Septic System
No
❑ The septic tank was inspected by a certified septic tank pumper within the last 3 ye'irs and was
found to be in satisfactory condition. A pumpers report is attached.
Records for this property contain a septic permit, design, final inspection approval d an as-built
drawing.
The site was inspected and the system location appears to be consistent with recorded documents.
The area of the on-sites stem appears to be maintained in an acceptable manner.
Was Operation and Maintenance a condition of permit approval?
Is a copy of current Operation and Maintenance re ort attached? N
Water System
Individual Water Svstenr
Yes No
❑ ❑ A water saAiple was taken by health department stXT and analyzed. Total coliform Bacteria were
determined be absent. LaborAtory results are attaclied to this re ort.
The well ca as inspected. The nit seal appears Ntisfactory
The well casin was inspected. The ing projected abo ground and the ground was sloped away
from the casin
The well site was inspe—heA. No septic sys ms, chemical stora a facilities, manure piles, animal
feedlots or other obvious sources of contamination appeared wit in 100-foot radius of the well.
Public Water Svstenr
Yes No
El F1 Records indicate w er-samplingrequirements are being satisfied.
Records indicate the ater FacNity inventory form is current.
Department files contatW,%yater s tern design and letter of approval
Soil Conditions
Test Hole#1 Test Hole#2 Test Hole #3
Soil Type: Soil Type: Soil Type:
Restr. Layer: Resin Layer: Restr. Layer:
Slope: Slope: Slope:
Distance to Shoreline Distance to Shoreline Distance to Shoreline
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PART 5: HEALTH DEPARTMENT OBSERVATIONS—FOR OFFICIAL USE ONLY
Primary Drain field
Staff inspected the primary drain field area and when available, pertinent records were reviewed. The
following determination was made
Yet No
❑ The system appears to be functioning adequately at the time of the inspection. (Holy applicable
ifs stem has been in use on a re lar basis for the last 6 months
Sanitary survey? Pass LJ Fail Lj Suspect
Not applicable
Water System
Staff evaluated the water system an the following dete tion was made
Yes No
❑ ❑ The water source consis f an indi ' ual well the appears to be a satisfactory s urce of potable
water for a single-famil rest n . The water was sampled and coliform bacteria were absent.
The water source is a public system that �in appears tocompliance with the applicable
regulations
Well Construction Pe it Pas Fail
PART 6: COMMENTS
INSPECTOR DATE
Important Notice: Findings & determinations of this review reflect observed conditions as they existed on the
day the evaluation was preformed. Absolutelytio claim is made by this office, expressed or implied
concerning the future success, failure or permit approval of the system and site evaluated.
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