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Home My WebLink AboutCRT2000-00206 - CRT Application - 11/21/2000 MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX I666 SHELT ON, WA 98584 (360) 427-900 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW AX 427--7798 Receipt No: Date of Payment: c� �;` S t Septic or Water Review ($85) : ��n��i � �?- U Both ($100) : Property Evaluation ($85+$50/Hr) : �� p —( t , SERVICES4 I�tSTRUCTIONS r' `E,., L 1- An application Is conidered caaplete when tM fee s d, Parts 1-4 of the ippl t on form are coWtated. (ass(starce will be provided upon request for complatfng Part Tro), the necessary paperwork it, attached, and - requfred soil evalwtion holes have been excavated- . 2. After a completed application is received, staff will Irmpect 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 addit)onal hourly rate of s50/hour as set forth by the Mason Canty Board of flealth. PART 1: APPLICANT/PARCEL IDENTIFICATION NAME OF APPLICANT � ( ? 91;� TELEPHONE %l tr-'r V':TE/HOUSE ADDRESS MBCLLING ADDRESS U-�+ `,:� ACREAGE c h' state 2 p ASSESSOR'S PARCEL NUMBER IL _ -EL _ /'1 /1 a Q 6 I LEGAL PROPERTY DESCRIPTION S.1 ..L_ .. SUBDIVISION (If Applicable) �ii^:.a�L;L ("/'" ,;i , DIV SLR LOT DIRECTIONS FOR LOCATING SITE ni Sketch location of property in this space. i If:\aJ-Szrz%E•HR6vrn/.w Revlalao 21261y! Page 1 PART 2: PURPOSE OF APPLICATION 2)1 OPTION ONE Vf1014= applying for a bank loan and the bank has asked for an evaluation Of the lowing: Septic System (Fee: $85) , • Age of System • Age of house • Number of Bedrooms • Name of Last owner _C • Is house currently occupied? �— -_EN_ — Attach pwaper's report, dated within lest 3 years, stating whether the system was pumped the size and condition of the tank, and the condition of the baffles. n U water System (Fee: $85) • Number of service connections on water system • If public water system: Nme o System , n LJ Both (Fee: $100) wFI N r Provide information shown above for both septic and water systems 2H. OPTION TWO r1 L_I I am applying for a building permit and environmental health has required an evaluation of the following: n L_I Existing Septic System (Fee: $85) , • Age of System • Number of Bedrooms • Name of Last Owner • Is house currently occupied? Yes —No • Attach purper's report, doted within lest 3 years, stating whether the system was purred, 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 fo new On-Site Sewage Disposal Permit. If the original septic permit cannot be located and system more than 5 years old, submit si ned as-built drawing from certified designer or professional engineer. M U Reserve Area for Future System Repair (Fee: s85) Two properly excavated pits are 4 ft deep must be ready for inspection by the department. rI U Both (Fee: 185) Provide information shown above for both septic system and reserve area m--%0m-srrr%E;atEvrEw.w Revision 212a/99 Pag'a 2 i $C. OPTION 7mms n I am interested in knowing in general terms the suitability of a parcel for septic system placement. (Feet $85 bass, 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 systeas, dimensions of the property, and location of arty 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 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I n I PART 4: AUTHORIZATION APPLICANT DATE w:lCw-SITSlvatavrSw.w RtVISI n 2126199 Page 7 PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY SA. DSTERK111ATION OF APPLICABLE STANDARDS The primary drainfield area must meet the following standards: n n U Meet current standards u--1 Standard marine system _ 4No overt failure n U Not applicable. The reserve drainfield area must have site characteristics that could support a septic system that would met the following standards: n n lJ Meet current standards. IJ Meet marine repair standards. n u Meet marine expansion standards. Not applicable. 52. NATSR SYSTEM ILS N INDIVIDUAL WATER SYSTEM n n U l_.I A water sample taken by health department staff and analyzed. l co(iform bacteria were determined to be ant. Laboratory results.are attached to thi report. n n ' L_l LJ The well cap was ins ted. The sanitary seal appears sati actory. n n l__I LJ Geeiwell casing was ins ted. The casing projec above grand and ground was sloped away from the rag. n n U u The well site was inspected. o septic terns, chemical storage facilities, manure piles, animal feed tots, or other obvious sources f con fnation were located within a 100 foot radius o the well. TY LIC R SYSTEM n n 1J u Records indicate water s tug requf is are being satisfied. n n 1J v Records indicate the ter Facility Invon ry form is current. n n LJ LJ Department files contain water system design letter of approval? SC. SEPTIC SYSTEM LES NO v,t' n Jam. U The capita tank was inspected by a certified septic tank pumper within the pest 3 years and fond 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. c7� n �( t__l The drainfield site was inspected, and appears consistent with recorded documents. I n JAY U The drainfield area appears to be maintained in an acceptable manner. n 1__l The drainfield area (the area where the drainfie(d is assumcd to be located based on office records and/or observed site conditons) appears to be maintained in an acceptable manner. p n j� U The drainfield area (the area where the drainfield is assured to be located based on office records, and/or observed site conditios) show rw indication of overt failure at the time of inspection. w:taw-SI7E11E7aZM 7r.w Revision 7/76199 Page 4 5D. BOIL CONDITIONS TEST HOLE #1 TEST HOLE #2 TEST HOLE #3 Depth to restr. layer Depth t restr layer Depth to restr- Mayer Soil Type: Soil Type: I i Soil Type: ---------------- FI ING SCORE Soil Type: Soil Depth: Slope: Parcel Size: Distance t Shoreline: SS. OTHER NOTES MM CO S R:1or�-SIT611XRhYfEII.X Revi�lon 2/26199 Page 5 I PART 6: HEALTH DEPARTMENT DETERDIINATION - OFFICIAL USE ONLY 6A. PRIMARY DRAINFIELD SYSTEM The primary drainfield area was inspected by staff and pertinent recoz�ds were reviewed. The following determination was made: l--1 l--i The system appeared to be functioning adequately at the time of inspection and and meets current design standards. The system appeared to be functioning adequately at the time of inspection. f1 tJ Not applicable. Comments: 6S. RESERVE DRAnTFIEL.D AREA The reserve drainfield area was inspected by staff and the soil was evaluated. Site characteristics indicated an area exists that could support a septlic system that would meet the following standards: I-1 �-i Current standards. rt U Marine expansion standards. n ^!tJ Marine repair standards, Treatment Standard y� Not applicable. Comments; 6C. WATER SYSTEM The water system was a aluated by staff and a following determination was made: tJ The water source co ista of an dividual well that appears to be EL satisfactory source o potabl water for a single family residence. The water was sampled, and colif cteria were found to be absent. I—I The water source is a ub is water system that appears to be in sub tantial compliance with app cable egulations. Comments: i .................................................................................. ....................... .................... ............................................................................. ............................. ................................................................................................ .................... Findings and determinations of this review reflect observed conditions as they existed on the day the eval tion was performed. Absolutely m 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 Cartmnity Development prior to issuance of developmental permit. INSPECTOR DATE h ZIO O —� N •SITEIMMEVIEW M RevLtml 21266199 Page 6