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Home My WebLink AboutCRT94-0195 - CRT Application - 7/11/1994 MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 EXHIBIT IV SHELTON, WA 98584 I (20 ) 427-9670 FAX 427-7798 APPLICATION FOR ENVIRONMENTAL WEALTH REVIEW Receipt No: L / Date of Payment: L RECE71VED Septic Review: JUL 6 1994 Water Review: Property Evaluation: HEALTH 3ERVICES INSTRUCTIONS IS. ( S 1. An application is considered complete when the fee is paid, Parts 1-4. of the application form are com leted. (.assistance will be provided upon request for completing Part Two), the necessary paperwork is attach , 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 project requires the excavation of more than 3 test holes, the department may charge the applicant an hourly rate of $37/hour as set forth by the Mason County Board of 8ealth. PART 1: APPLICANT/PARCEL IDENTIFICATION .......................................................................................................................................................... ................... .......................................................................................................................................................... ................... NAME OF APPLICANT pick (j;DA2*A&50QLEPHONE 3Z^ SITE/HOUSE ADDRESS E, �p3' 41(yµ%N1�J" JOB) Uh11o"N. 98S}2 MAILING ADDRESS A (, A 9es O ACREAGE O . C y 9tsCe Zip ASSESSOR'S PARCEL NUMBER LEGAL PROPERTY DESCRIPTION C1 T SUBDIVISION (If Applicable) ' DIV BLK LOT DIRECTIONS FOR LOCATING SITE N1 W D V/z St E t S ft L Arc' Jt✓ Sketch location of property in this space. UMIOW �o -�� ALOERBP.oOK t�� / srM s 4a. 51 le,4sed 12/29/93 PART 2: PURPOSE OF APPLICATION ............................ ................ .................. .............................................................................. ........................................................... 2A. OPTION ONE 0 1 am applying for a bank loan and the bank has asked for an evaluation f the following: Septic system (Fee: $50) • Age of System • Age of House • Number of Bedrooms • Name of Last Owner • Is house currently occupied? • Attach pumper's report, dated within last 2 years, stating whether the system was pumped, tie size and condition of the tank, and the condition of the baffles. Water System (Fee: $40) • Number of service connections on water system • If public water system: Both (Fee: $68) . Provlde information shown above for both septic and water systems 2B. OPTION TWO am applying for a building permit, and environmental health has requi- ed an evaluation of the following: R�F fisting Septic System (Fee: $50) • Age of System • Number of Bedroom. • Name of Last Owner • Is house currently occupied? • Attach pumper'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 si ned as-built drawing from certified designer or professional engineer. ❑ Reserve Area far Future System Repair (Fee: $40) 0 Iwo properly excavated pits are 4 ft deep must he ready for inspection by the department. Both (Fee: $50) . Provide information shown above for both septic system and reserve area 2C. OPTION THREE 1 am interested in knowing in general terms the suitability of a parcel for septic system placement. (Fee: $40 + $37/hour) Describe the intended use of the property and the reason for requesting the review: No. 51 3ev'sad 12/20/93 PART 3: PLOT PLAN ..................................... ............................................... ..................................................... .................................... Use this space to dray a detailed plot plan, or attach one to this application. A detailed plot plan ig one that shows the precise location of the test holes, existing septic systems, dimensions of the property, and 3ovation of any wells, roads, or other buildings an the property. Ole NP o(� ' �'k � PART FOUR: AUTHORIZATI ...... ................... ............. .................. ......................................................................... ....................................... ......4� APPLICANT DATE Remised "2/28/93 3, Re�i.ed 12/28/93 'PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY ..................................................................................................................................................... ........................ 5A. DETERMINATION OF APPLICABLE STANDARDS The primary drainfield area must met the following standards; ElMeat current standards El Standard marine system F1No overt failure FJ Not applicable. The resarve drainfield area must have site characteristics that could support a septic system that would met the following standards: 0 Meet current standards. ❑ Meet marine repair standards. nMeat marine "pension standards. F1 Not applicable. 5B. WATER SYSTEM YES NO INDIVIDUAL WATER SYSTEM A water sample was taken by health department staff and analyzed. Total coliform bacteria were determined to be absent. Laboratory results are attached to this report. ElEl The well cap was inspected. Th. Sanitary seal appears satisfactory. The well casing was inspected. The casing projected above ground and ground was sloped away from the casing. F] The well site was inspected. No septic systems, chemical storage facilities, manure piles, animal feed lots, or other obvious sources of contamination Were located within a 100 foot radius of the well. PUBLIC WATER SYSTEM Records indicate water sampling requirements are being satisfied. nF] Records indicate the Water Facility Inventory form is current. El11 Department files contain no information indicating the system is out of compliance with state or local water system requirements. o-(zL'( 5C. SEPTIC SYSTEM 3k ('&A) � jl� 7T-- 1-13-qti, 0 YES No f'jv""'N,� � 11�— SU O'�"ho" 0-3pCkic" Eln The septic tank was inspected by a certified septic tank pumper within the past 2 years and found to be in satisfactory condition. A pumper-s evaluation is attached to this report. ElEl Records for this property contain a septic permit, design (if required), final inspection approval, and FcOT as-built approval. ❑ F1 The drainfield site was inspected, and appears consistent with recorded documents. b El [I The drainfield area appears to be maintained in an acceptable manner. 0 0 The drainfield area (the area where the drainfield is assumed to be located based on officq records and/or observed site conditons) appears to be maintained in an acceptable manner. The drainfield area (the area where the drainfield is assumed to be located based on officB records and/or observed site conditons) show no indication of overt failure at the time of inspection. 10. S1 . Revised 12/28/93 5D. SOIL CONDITIONS TEST HOLE #1 TEST HOLE #2 TEST HOLE #3 7m �' aJ.611JLa 1 <D—/o tell( Depth of root pen. : Depth of root pen. : Depth of root pen. : Depth to restr. layer Depth to restr. layer _ Depth to restr. layer _ Soil Type: Soil Type: Soil Type: Vertical Separation:' Vertical Separation:" Vertical Separation: Curtain drainable? (Y/N/NA) : Slope (%) : Shoreline? (Y/N) : Minimum lot size:' Designer level: Vertical separation is the depth of unsaturated, original, undisturbed Soil of Types 2-6 that Exists between the bottom of the subsurface absorption System and a restrictive layer or the watertable. ve ical separation for purposes of designating designer level will be calculated by the health department based or a 12-inch deep 5E. OTHER NOTES AND COMMENTS .ter' e e " -S q_2 " �o li f ca - wo -)Al 0(c-4 ^ co a e 'No. 51 caul sea 12/28/93 1�, - t lnll e7 �'-� (g�Nl✓e/ wee qoa (.91 p &-it /5P. , SOIL CONDITIONS (` 4 0n( / TEST HOLE #1 TEST HOLE #2 TEST HOLE #3 r1 4)_(�' S_4,,dj i00, Fill J`'1' N^2Q $-9�+9 14. ,J 0 -(� 5 4vu �puti Fi Il %-ay- v`^Dl'�c� S.a�� ip✓�� 3✓uq,tl- 1paiie a(o vtio Etleb-b�i9�}ly co,�-rc+f S�Iyloa� Flu �y_3y d� ?w✓ack fw -saw Pc ok6 O� -✓erg( cowp�� d exis�tv5 SyrJtw C2v,.i�ged Rya 2�-LAS,_ grey - very Co,, je,1 — �"7 (0,,,.,0,44-eo to CQv'A"Ac.d wUJ g° 4 'i -uwvMka '7i1 Depth of of root pen. : N—Mrs Depth of root pen. : P0Ax- Depth of root pen. : Depth to restr. layer Depth to restr. layer G1• Depth to restr. layer Soil Type: Soil Type: Soil Type: Vertical Separation:" Vertical Separation:r Vertical Separation:' Curtain drainable? (Y/N/NA) : Slope (%) : Shoreline? (Y/N) : Minimum lot size:" Designer level: Vertical separation is the depth of unsaturated, original, undisturbed soil of Types 2-6 that exist9 between the bottom of the subsurface absorption system and a restrictive layer or the watertable. Vertical separation for purposes of designating designer level will be calculated by the health department based on a 1 -inch deep 5E. OTHER NOTES AND COMMENTS —I—alfJ4 PQJ CC11AV-eA,4-bc1w - ll-e v S e +Lx 1 o d Nc l nr 'c -2 D v� du✓ iS Ce A"vA -e L / j Cx No. S1 Revised 12/28/93 PART 6: HEALTH DEPARTMENT DETERMINATION - OFFICIAL USE ONLY .................. ........................................................................................................................................................... 6A. PRIMARY DRAINFIELD SYSTEM The primary drainfield area was inspected by staff and pertinent records were reviewed. The following determination has been made: The system appeared to be functioning adequately at the time of inspection and and meets current design standards. EJThe system appeared to be functioning adequately at the time of insDection. 1:1 Not applicable. Comments: 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: Current standards. Marine expansion standards. Marine repair standards, Treatment Standard Not applicable. Comments: 6C. WATER SYSTEM The water system was evaluated by staff the following determination has Deen made: The water source consists of an individual well that appears to be s. satisfactory source of potable water for a single family residence. The water was sampled, and coliform bacteria were found to be absent. The water source is a public water system that appears to be in substantial compliance with applicable regulations. 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 L= DATE � -Qb—M Na. Si ?.,ised 12/28/93