HomeMy WebLinkAboutCRT2007-00018 - CRT Application - 4/11/2008 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)275-4467
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: S5200700000000000409
CRT2007-00018 Payment Type: Check Property Evaluation
Date of Payment: 03/08/2007
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
RECEIVES'
I
Parcel Number: 321275300185
Site Address: 124 E OLDE LYME RD SHELTON
Brief Legal Description: LAKE LIMERICK 4 LOT: 185
Driving Directions: ON MASON LAKE RD PAST 1ST LAKE LIMERICK ENTRANCE TURN RIGHT
ON OLD LYME RD, AT 1ST CUL-DE-SAC TURN RIGHT & PROPERTY IS AT END.
PART 2. TYPE OF REVIEW
Septic System
Age of system:
Age of house: Oew
Number of bedrooms: 2
Name of last owner: N 4,
Is house currently occupied?: N/A
If not occupied, how long has it been vacant?: WA
Water System
Number of service connections on the water system?: t
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.
LOT 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.
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PART 4. HEALTH DEPARTMENT FINDINGS — OFFICIAL USE
Septic System
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 inspection approval and an
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 current Operation and Maintenance report attached?
Water System
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.
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, manure piles,
animal feedlots or other obvious sources of contamination appeared within 100-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 Hole #3
Sal Type Sal Type Sal Type
Restr. Layer Restr. Layer Restr. Layer
Slope Slope Slope
Distant to Shoreline Distant to Shoreline Distant to Shoreline
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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
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? Survey Results
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 coliform 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
Site Evaluation: After the fact as built attached. CEW
INSPECTOR LJ DATE 3/28/2007
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.
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