The URL can be used to link to this page

Home My WebLink AboutCRT2011-00003 - CRT Application - 3/18/2011 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)275-4461 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: S6201100000000000435 CRT2011-00003 Payment Type: Check Septic Date of 03/18/2011 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 Applicant: JANE MCCUISH Telephone: 360-871-2345 Mailina Address: PO BOX 702 Citv: MANCHESTER State: WA Zip: 98353 Parcel Number: 123305300001 Site Address: 130 NE SANTA MARIA LN BELFAIR Brief Legal Description: BEARDS COVE DIV 6 LOT: 1 Driving Directions: Sandhill to left on Larson Blvd. to left on Larson Lake Rd. to right'on Santa Maria Lane. Site on right. PART 2. TYPE OF REVIEW Septic System Age of system: Age of house: Number of bedrooms: Name of last owner: Is house currently occupied?: 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 APPRO�AL. Describe the intended use of the property and the reason for requesting the reviev� 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 doles, 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. T CRT2011-00003 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 lastll3 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 appr val 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 manner. 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 coloorm 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 g ound 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 1 0-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 Soil Type Soil Type Soil Type' Restr. Layer Restr. Layer Restr. Layer, Slope Slope Slope Distant to Shoreline Distant to Shoreline Distant to Shoreline CRT2011-00003 3 of 4 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 satisfacry source of potable water for a single-family residence. The water was sampled and col form 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 Septic Review: Due to non use, Mason County Public Health can not comment on the functionality of the septic system. According to the applicant, the home has been vacant for approxi nI,ately two years. INSPECTOR �uo�„� ,�, DATE 3/23/2011 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. CRT2011-00003 4 of 4 FROM BANK�OF AMERICA HOME LOANS (THU)MA 2011 14 :09/ST. 14:09/No. 826655873 P 1 C--) � MASON COUNTY PUBLIC HEALTH 426 W CEDAR ST,PO BOX 1664,SMTON,WA 98584 SHELTON(360)427-9670,Fm:97Tb ELMA(360)482-5269, BELFALR(360)275.4467 WBB-. htwo jwwn'snason ws.us PAX,(360)427-779s APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW PERMT Bp TYPE OF REVIEW CRT Receipt Number (G t ❑ Septic and Water $310 �J �Cash Septic 5170 Cash Check ❑ Water $191 (lndlvidual and Two Party) / 3 Date of Payment 7 ❑ Group B WS Evaluation $sss.00lhaur beycild 1 how) ww ❑ Property Evaluation S258 0 Rasample $22 lab fee A porlant Notled:Findings&determtnotlow of this review reflect observed conditlow as they 'st on the day the evaluation was performed Absolutely no claim!s mods by this gfltce, expressed or 1 i. Implied concernMlt the future success, faihm or permit aQ»ravel ofthe sysrem and sire evaluared. *"`FILL OUT APPLICATION COMPLETELY AND ACCURATELY""` I An application is considered complete when the he is paid, parts 1,2,and 3 of this application form are completed,necessary paperwork is attached(i.e.pumpers report)and when required 11 evaluation holes have been excavated. ✓lf ,,x l PART].APPLICANT/PARCEL MENTIV'ICATION Qn e) 6C 74MWit!cL tr l t� • Q�J217f- �-+7r Name of Applicant e A `Z Ut 5 h _ Telephone�(p / c4- S Mailing Address of Applicant -70 Z city 904) state te)A— zip �353 a 3 3 0 0 12-digit Tax Parcel No. 1�2 'M.S .� -- � 0 Site Address D �� f t / izL J �a n L ri s,v Brief Legal Description Driving Directions A01-14—h—shme k6 77J SgnQ 2. rin Sa n f� p ia. 2 e-- PrU67YA ofcJ �r�l Page 1 of 4 SIZ 80tL•OLL•09C e)iJawd ;o WE] Wd 9'Z0 Lt-JeW-"OZ FROM BANK OF AMERICA HOME LOANS (THU)MAR 17 2011 14 :09/ST. 14 :09/No. 6826655873 P 2 PART 2: TYPE OF REVIEW Cl Septic System a Age of system • Age of house • Number of bedrooms • Name of last owner • Is house currently oeoupied7 0 YES �VNNO e If not occupied,how long has it been vacant? K ❑ Water System a Number of service connections on the water stem? • If a public water system,name of system btOAL65 (7V • WFI number ❑ Property Evaluation(Roll loge) Property evaluations provide, in general tbrma,the suitability for a parcel for septic system placement. TIES 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,Location of, s Existing Septic System,Dimensions of Properly,Location of any Drinking Waster Sources (wells,springs, etc)]toads,Easements,Surface Water,and Buildings on the property.(skip P 3 for Group B water system review) A fV* X 10Z 2-(o Aer COBWASS Applicant s Signature: Date lPage 2 of 4 I .. 5/g SOU-OLL-09f e�iJawy to tueg Ad i920 LL-JeW-IIOZ FROM BANK OF AMERICA HOME LOANS (THU)MAR 17 2011 14 :09/ST. 14 :09/No, $826655873 P 3 PART 4:HEALTH DEPARTMBNT FINDINGS—OFFICIAL USE ONLY Septic System Yj No ❑ The septic tank was inspected by a certified septic tank pumper within the last 3 years�nd was found to be in satisfaotory 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 Indlvldwrl,iYarar System Ye ❑ ❑ A water sample was taken by health department staff and analyzed.Total collform bao aria were determined to be absent,Laboratory results are attached to this report. ❑ ❑ The well cap was inspected.The sanitary seal Appears Aatiafaet'Ory. ❑ ❑ The well easing was inspected.The coring projected above ground and the ground sloled away from the casing. ❑ ❑ The well site was inspected.No septic systems,chemical storage facilities, manure pile, animal feedlots or other obvious sources of contamination appeared within a 100-foot radius of the well. Public Wder System Q ❑ 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: Restrictive layer. Restrictive layer. Slope: Slope: Slope: Distance to Shoreline:. Distance to Shoreline: Distance to Shoreline: P%p3 of 91b 8014-OL4-09E RI!JawV !° 1Oe9 Wd i9Z0 LL-JTW-"OZ FROM BANK OF AMERICA HOME LOANS (THU)MAR 17 2011 14 : 10/ST. 14:09/NoA826655873 P 4 PART 5:HEALTH DEPARTMENT OBSERVATIONS—FOR OFFICIAL USE ONLY Primary Dralafleld Yes U2 0 0 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 0 ❑ The water source consists of an individual(or a two-party)well that appears to be a satisfactory source of potable water for a single-family(or two single family) residence(s).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. 0 ❑ Well Construction Permit ❑ Pass ❑ Fail rART d:COMMFN[9 INSPECTOR DATE Important Notice:Findings&determinations ofthis 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. i Pap 4 of 4 Certification Application Farm doc Updated s/2007 S!S SOLZ-OLL-09£ eD'Jawb 10 hies Wd I� q zo Li•JeW•liOZ 10/08/2010 12 45 FAX 00 9/0 20 ...t::A..-.,. _ .-_. -,• --- - -:_— ,;cam _.._.t -__.-- --*'-'-r :: t- =-.c - - -77 Y vim. f jo � f y. 1w _ - r HT. . �Y�j}.�t1y�I��w�nw✓�t.Y✓�11 � t-. F - -- _ - —` y ;FAir .yf i sT+ri: • • -ro ofu" Arta' 10/08/2010 12 48 FAX 1jD00 0/0020 _ �t 1�.. E I �"" � — 5 s - - j —, :w't�--ors-- +•z+-t F+a. msx 1, „-xl"Z-•'r`r -. „"'� - __ V i __ .--_ :�T _.��"--y1s-:_ 1 h t ..-�tqf � Y t . •.�'. is _ Y--.=t . -�-F•: t-- e ` _ era..Y: `'..�{•.r+ S +.-+_ti.—v-•yy -ee.Yi' _. -..:L v. 1 F �.. 't / Z�-Yerg �Ci'—�--E-`�.._ y .ate �y - � iC ....- ."-Esf- s-1-•*..f^.1 _ .i—. � ��--K .Y{`-^:fin• 1 tL s Y vrv� �1"'1ri s r�a 'E iv mi ,,em�s3�. � � � t a • E R ��/�T :�JL' t�'it 10/08/2010 12:47 FAX 000 1/0020 i 4.2 1 i E E � { • a F 18 a � . t o l. gNJ 1p dB nj ;W-12.22 Y}97 AcUaoonstte Servk 3603760649» 3603760012 PIII ■ ■ SLPTIC SERVICE'Ii 1 IN I III KI15AP PENINI-d N A rartutm Opwatb s ti mormermr•P Uw0wo t rbr KffSAP PKMC 6 MASM VA NiE5 PO Box 1027 -Port Orchard,WA 98386 Invoice# 7252 (3 8 01 8 76-6769•Fax:t3803 876-0849 '/ acLorronrhxL9wdtafflafnee Date�o2 vv •� Customer /.`Z ��1s� , ,u- Job Location 1,� _ --- Address l'� A ILA, - ----. CitylState,Zip� t fi 1(t- �g�CirU Job Phone Tank Liquid Level td Main Line 0 Pump Repair O.Jelter \ 0 L ter t�1Qormal 0 High' 0 Low Q Camera ❑Service Repair )lfUncover Tank ❑Ta k open Approx.Tank Size:/ / Gals, Locating&Digging Hours: Ilk d PIII Gallons Ptmtped: �� `f Time In: Time Out: Service Men: Truck No. I /��0 Check 0 Cash 0 MCMsa W(AccOunt Product/Services unit price -TotalAmountl _.__. f NIL i te- • i fm e, e& kvx-kb I Sub Total 7�0 Signature: 10hwnty Welder-Action On Site 9ervkec wilt not assume Aeblllry(Or any propsny damage I Sale6 Tax i or any equipment damage for any work beyond the curb KM. - Total Balance due upon completion unless previous arrangements have been made. Due Upon Receipt IMGO C 2/0002 Pumping Repa.d . fiacklnq#; 1 Name: CHI 14 SGHAP*Ok Sit Address: 119 N�SffS14 MARgA>AW '. BedYpr 1NA: ' WM Address: 130'1AR SWTA.WRIA LAM Bslplit,,Y1U� A> a9d Provider FtvYnPrpperb'� i — RRKid@tai. - :Mrtoagmnsrn Level; . Sekated Setvgre I tovlder. AcUcfn:AtYe o`Ssrvk s,ki#t .. .. Selsnt@d SerAce PMVMsr 10 ,RsportFlletiBy: Titt�eCase CsxnPonout that was Pumpsd.Inspected or maintained: t: Conventlonab(Ptessurized) 8ept)clploldlnq Tank Gallons Pumped: 144 Tout G.AlonsPeinped: 1526 - . srrtmMaaon: t e - t to Dats.Serviced: 1 12=010,. 12/ ?Jk01'0 :p1N�eelMC."^yMe-�nw.yIl�lessage tip Y ,VYM�R�MY�M. •.• ( 6Y {. 54!heiprovrder4DNLYt/ Dbposel Location: BfoyCla. 1m .. • �rtgons DNposed: was*Type: Nonb, eq.dsd Gg 4onftpal(Pnestirized)Quastkrns 4hpaNshaW7 aervic0 event ®.Yes NO ibis MpW only de plM.lbe COMING s4ttlt8 Hite OFSWVIM end Ceder He ooteiaonr oriya:8tet6¢Het4,ThY.roptrFdA'p`iA�eydieee'boW •Dte.;yaHp,wn pertbndtn.tlieAiWn terdar rNtrMt4W.ggrareMoondsuts dues. '. . "filet•eempxoraniMC6o0adoc+erwta9401^�+e10�'• . . Report Active S1Ugogn.Color l4Y:t8amVN1'R2WI1qd. .. . htt�,Jxaacmaay.bi7/Puimp/serviae_Reports.aspx7ha=lac6i=lacpErildeid* 5o804&p&Wtj,.. 3119C2o1T