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Home My WebLink AboutCRT2006-00132 - CRT Application - 9/21/2006 MASON COUNTY bEPARTMENT OF HEAZTH SERVICES 426 W CEDAR ST., PO BOX 1666, SHELTON,WA 98584 SHELTON(360)427-9670,Ext: 352, ELMA(360)482-5269, BELFAIR(360)275-4467 WEB: huw//www.co.mason.wa.us FAX: (360)427-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW PERMIT NUMBER PAYMENT INFORMATION TYPE OF REVIEW CRT Receipt Number Lam; Septic and Water $250 ❑ Cash ❑ Septic $150 ❑ Check ❑ Water $150 rA� I [I Property Evaluation $150 lx 6 Date of Payment ❑ Resample $18 lab fee Important Notice: Findings & determinations of this review reflect observed conditions as they exist on the day the evaluation was performed. 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 Mar Go_�+--� NameofApplicant D i Annce M IMr Telephone 3eD-430- 91 r-'7 Mailing Address of Applicant Q q0 I Ta h w 1 alp Ala CKSM i fi-% tie) City �&I T0. t Y State W A Zip OI 8's 2 0 12-digit Tax Parcel No. 2— ' L 0__ -- q_ �P_ -- 0 421 Site Address U 0101 -T0.tiuAjo-Brief Legal Legal Description Le Driving Directions ( 'fin l_b ve P` tb -7-A f-1'tkUA , TD AA Page 1 of 4 f , PART 2: TYPE OF REVIEW ❑ Septic System • Age of system • Age of house • Number of bedrooms 1 • Name of last owner • Is house currently occupied? YES ❑ NO • 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 P.`Zt C �S�i yam( Ct • WFI number ❑ Property Evaluation (soil logs) Property evaluations provide, in general terms, the suitability for 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 detailed plot plan to this application. The plot plan should include the following: North Arrow, Location of Test Holes, Locati�n of Existing Septic System, Dimensions of Property, Location of any Drinking Waster Sourcfs (wells, springs, etc.) Roads, Easements, Surface Water, and Buildings on the property. I LOT SIZE Izl X �!+ Acres COMPASS Applicant's Signature: —T nW Q Con44-A-- Date Page 2 of 4 I 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 years and was found to be in satisfactory condition. A pumpers report is attached. ❑ Records for this property contain a septic permit, design, final approval and as as-built drawing. ❑ The site was inspected and the system location appears to be consistent with recorded documents. ❑ The area of the on-site system appears to be maintained in an acceptable manner. ❑ Was Operation and Maintenance a condition of permit approval? ❑ ❑ Is a copy of a current Operation and Maintenance report attached? Water System Yes No Individual Xare m ❑ ❑ A water sample was taken by ealth departm analyzed. Total coliform bacteria were determined to be absent. boratory resand to this report. ❑ ❑ The well cap was inspected. The s nary appears satisfactory. ❑ ❑ The well casing was inspected. The c ng projected above ground and the ground sloped away from the casing. ❑ ❑ The well site was inspected. septic syst s, chemical storage facilities, manure pile, animal feedlots or other ob ous sources of c tanimation appeared within a 100-foot radius of the well. Yes No Public Water System ❑ ❑ Records indicate water-sampling requirements are being satisfied. ❑ ❑ Records indicate the Water Facility Inventory form is current. ❑ ❑ Department files contain water system design and letter of approval. Soil Conditions Test Hole #1 Test Hole #2 Test Hole #3 Soil Type: Soil Type: Soil Type: Restrictive layer: Restric ' ayer: ctive layer: Slope: Slope: Slope: Distance to Shoreline: Distance to Shoreline: Distance to Shoreline: Page 3 of 4 ------------ ' PART 5: HEALTH DEPARTMENT OBSERVATIONS—FOR OFFICIAL USE ONLY Primary Drainfield Yes No ❑ The system appears to be functioning adequately at the time of the inspection. (Only applicable if system has been in use on a regular basis for the last 6 months.) ❑ ❑ Sanitary survey? ❑ Pass ❑ Fail ❑ Suspect ❑ Not applicable Water System Yes No ❑ ❑ The water source consists of an individual well that appears to be a satisfactory source of potable water for a single-family residence. The water was sampled and coliform bacteria were absent. ❑ ❑ The water source is a public water system that appears to be in compliance with applicable regulations. ❑ ❑ Well Construction Permit ❑ Pass ❑ Fail PART 6: COMMENTS INSPECTOR DATE Important Notice: Findings & determinations of this review reflect observed conditions as they exist on the day the evaluation was performed. 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. Page 4 of 4 Certification Application Form.doc Updated 1/2006 ¢Y,l, C O O 6l A CD m Z ZZ. .M D .I :1�. ' m0 y< 0 fr,n p ; .�i@ D (,..y i @ O~� RI es"m_ I� C : z O RI 7Zc - JZC m m m O9 S c 23 zU i m r < :0 C..m � : � 3 3 O > c r D v : Dm v m m y m m 2� H , ( Z m m v -.._ _p_. -. �_.... y c q m < m C ❑ Z `o{ Z 0C z c` x 33 9 D Z a E _. e a ..... e _En O O r z rD- O r I i i a i Q i = Z m r Z L.. y _a a 1 p — x _ Om ❑ cn V T i Cmf 9 m < ax i �' m v x ❑ C m ( ( , _. _ p 5 3 O O 9 ? S ` E '� y m Z m ° y N m s_ t i i O cn ra a 7_C mr ' a ❑ ❑ E _ _ m f ❑ ❑ N m N Do Oi _ a --, _ - 3 m z V m is l a m z v ; ❑ P O y Z m .._ fn E f [ ti O ° 9 O z { i = t O ❑ m z m °o ,. m m t 5 m 8 0 _ m v S m 3 z v o Z o D \ m n . tea L/ i z _6 n CO) .. � c D x C . Z Z Z Z m t _ AO n ' i i m r n A D o 7 z n n0 m x rD- v ` n m Z ;-j l J m z z Cl) ❑ ❑ O x c ® 9 v m U m 8 01 o m D D CD COO O � m � G7 t0 o D IiTt n 0 1 f, � = W 1 vO D 0 o r m O x m V a Z m m O n O 3 " m ® 9 � N-I 0 3 O H O m m y m m m z v Z � Dr y x a _ G n 0 Inc < co c) D cZi D m n ? D m n x p y 3 z > °> '� .�, O ° O L9 co z m m m 0 z D+ F x m m 0� c w � O mOpi a O x m ym2 = ca .n m m <_ m N < �"m I N m 0 :u m 0. D A MASON COUNTY DEPARTMENT OF HEALTH SERVICES �. 426 W CEDAR ST., PO BOX 1666, Shelton WA 98584 SHELTON (360) 427-9670 Ext: 352 ELMA (360)482-5269, BELFAIR (360) 275-446 WEB: http://www.co.mason.wa.us FAX: (360)427-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW PERMIT NUMBER PAYMENT INFORMATION TYPE OF REVIEW Receipt Number: S2200600000000003096 CRT2006-00132 Payment Type: Check Septi &Water Date of 09/21/2006 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 be 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 Applicant: DIANNA MINOR Telephone: 360-830-9157 Mailing Address: 6901 TAHUYA BLACKSMITH RD 3530 NE OLD HWY Citv: BELFAIR State: WA Zip: 98528 Parcel Number: 223047690201 Site Address: 6901 NE TAHUYA BLACKSMITH RD BELFAIR Brief Legal Description: TR 8-A OF SURV 12/68 LOT A OF SP #1934 Driving Directions: PART 2. TYPE OF REVIEW Septic System Age of system: Age of house: 2 YEARS Number of bedrooms: 1.00 Name of last owner: MINOR Is house currently occupied?: Occupancy 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: WFI number: Proprety 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 The description of the intended use is not included in this report. PART 3. PLOT PLAN Use the space below to draw a detailed plot plan, or attach a detail plot plan to this application. The 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. L T SIZE x Acres The applicants plot plan is not included in this report. Applicant Signature: Signature is not included in this report. Date: The date is not included in this report. CRT2006-00132 2 of 4 PART 4. HEALTH DEPARTMENT FINDINGS -- OFFICIAL USE Septic System Y The septic tank was inspected by a certified septic tank pumper within the last 3 years and was found to be in satisfactory condition. A pumpers report is attached. Y Records for this property contain a septic permit, design, final inspection approval and an as-built drawing. Y The site was inspected and the system location appears to be consistent with recorded documents. Y The area of the on-site system appears to be maintained in an acceptable mariner. N Was Operation and Maintenance a condition of permit approval? Y Is a copy of current Operation and Maintenance report attached? Water System Individual Water System A water sample was taken by health department staff and analyzed. Total colif rm bacteria were determined to be absent. Laboratory results are attached to this report. The well cap was inspected. The sanitary seal appears satisfactory The well casing was inspected. The casing projected above ground and the ground was sloped away from the casing The well site was inspected. No septic systems, chemical storage facilities, ma ure piles, animal feedlots or other obvious sources of contamination appeared within 10 foot radius of the well. Public Water System Records indicate water-sampling requirements are being satisfied. Records indicate the Water Facility Inventory form is current. Department files contain water system design and letter of approval Soil Conditions Test Hole #1 Test Hole#2 Test Hol #3 Soil Type Soil Type Soil Type Restr. Layer Restr. Layer Restr. Layer Slope Slope Slope Distant to Shoreline Distant to Shoreline Distant to Shoreline CRT2006-00132 i 3 of 4 i ,PART 5: HEALTH DEPARTMENT OBSERVATIONS -FOR OFFICIAL USE ONLY Primary Drainfield Staff inspected the primary drain field area and when available, pertinent records were reviewed. The following determination was made Y The system appears to be functioning adequately at the time of the inspection. (only applicable ifs stem has been in use on a regular basis for the last 6 month N Sanitary Survey? Survey Results NA Water System Staff evaluated the water system and the following determination was made The water source consists of an individual well the appears to be a satisfactory source of potable water for a single-family residence. The water was sampled and coli orm bacteria were absent. The water source is a public water system that appears to be in compliance with the applicable regulations Well Construction Permit Permit Status PART 6: COMMENTS Water Review: connected to a group A public water system. You will need to contact t e state department of health for any information on Erickson Lake Tracts water system. INSPECTOR &_Z4 DATE 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. CRT2006-00132 4 of 4