HomeMy WebLinkAboutCRT96-0060 - CRT Application - 4/4/1996 MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST 0F1 ICE BOX 1666
SHELT N, WA 98584
60) 427-9670
PAX 42 7-7798
APPLICATION FOR ENVIRONMENTAL HEALTH REVIE
Receipt No:
Date of Payment: 1/ /1/_ 1
N 01 f 0 Trau
Septic or water Review
Both $100 .
Property Evaluation ($6 + 45/Hr A R 0 4 1996
INSTRUCTIONS -45 J+GAS SERVlCEP
-t l�
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 at ached, and
required soil evaluation holes have been excavated.
2. After a completed application is received, staff will inspect the property and provide the applic nt 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 $40/hour as set forth by the Mason County Board of Health.
PART 1: APPLICANT/PARCEL IDENTIFICATION
NAME OF APPLICANT C!U 6 V 6 L( (?4D IIA,, OOA )eCo TELEPHONE 7 S "S S�Q
SITE/HOUSE ADDRESS (oS-lo
MAILING ADDRESS 0 , U C
Li % e 1 ACREAGE
P
ASSESSOR'S PARCEL NUMBER ( / - —2 -
LEGAL PROPERTY DESCRIPTION l
SUBDIVISION (If Applicable) DIV BLK LOT
DIRECTIONS FOR LOCATING SITE k::. = -
TOo E lL -
Sketch location of property in this'space.
H:\ON-SITE\EHREVIEW.W Revis be 01107196
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: $62) j1
((( - Age of System
Age of House
• Number of Bedrooms
Name of Last Owner
Is house currently occupied? J
Attach pumper's report, dated within last 3 years, stating whether the system was pumpe the size and
condition of the tank, and the condition of the baffles.
n
LJ Water System (Fee: $62)
• Number of service connections on water system
If public water system:
q� ame o ys em
Y� Both (Fee: $100) WFT Num er
Provide information shown above for both septic and water systems
2B. OPTION TWO
F—I
u I am applying for a building permit, and environmental health has required an
evaluation of the following:
n
L-J Existing Septic System (Fee: $62)
Age of System
Number of Bedrooms
• Name of Last Owner
Is house currently occupied?
des __Io
• 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 or 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.
n
L-J Reserve Area for Future System Repair (Fee: $62)
Two properly excavated pits are 4 ft deep must be ready for inspection by the department
n
LJ Both (Fee: $62)
Provide information shown above for both septic system and reserve area
2C. OPTION THREE
n
LJ I am interested in knowing in general terms the suitability of a parcel for septic
System placement. (Fee: $62 base, plus $45/hour after first hour)
Describe the intended use of the property and the reason for requesting the review:
H:AON-SITE\ERREVIEW.W Revision 0110]/96