HomeMy WebLinkAboutCRT96-0183 - COM Application - 10/7/1996 117
MASON COUNTY DEPARTMENT OF HEALTH SERVICES 04
POST E BOX 6
SH WA 9 4
_ 7 9�$p
7-
APPLICATION FOR ENVIRONMENTAL HEALTH REVIEM U
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eipt No: AM(Q;�Ii5
Date ofoPayment; - I O
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Septic or Water Review ($62) : I T Both ($100) : O
Property Evaluation ($62+$45/Hr) :
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INSTRUCTIONS
1. An application is considered complete when the fee is paid, Parts 1-4 of the application form are completed. ,�jp
(assistance will be provided upon request for completing Part Two), the necessary paperwork is attached, and V 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 site review requires more than 1 hour of work, the department will charge the applicant an al�dditional
hourly rate of $40/hour as set forth by the Mason County Board of Heal h2;�
PART 1: APPLICANT/PARCEL IDENTIFICATIO 8k�j ' l�C hm
----�F� �'\\ d NAME OF APPLICANT /1l ryp L C.D VYl T (3EO ) 7pZ ELEPHONE - oZ 5�53
SITE/HOUSE ADDRESS n F I CI I Sites OC
MAILING ADDRESS t 7yl Sid eS u-)
e( G` - 1w/ r7- ACREAGE
l y a e ip S
ASSESSOR'S PARCEL NUMBER a. - 6 0 Q- / 6
LEGAL PROPERTY DESCRIPTION � 2 1 (o ni• Svr V e / ,///Y -oT.Z
SUBDIVISION (If Applicable) DIV BLK _ LOT
DIRECTIONS FOR LOCATIIQG SITE lieu./ creeK - Qwq - ej LF+ O �
�Fs} L,fe✓Id,.-V _ l vwe d - R6,. T es -re LFt on C ewe Saco
Sketch location of property in this space.
I - - ec,.r Cre 2LZ (�cwuf>co 4.c.� I
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Sipes, wcyl,
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H:WN-SITE\EHHEVIEW.W Revi4 01/07/96
PART 2: PURPOSE OF APPLICATION
2A. OPTION ONE
I am applying for a bank loan and the bank has asked for an evaluation o the
following:
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LJ septic System (Fee: $62)
Age of System
Age of House .{
Number of Bedrooms
Name of Last Owner ���h
• Is house currently occupied? '-r
es �Io
• Attach pumper's report, dated within last 3 years, stating whether the system was pumped, he size and
condition of the tank, and the condition of the baffles.
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U Water System (Fee: $62)
Number of service connections on water system
• If public water system:
ame o ys em
Both (Fee: $100) Wrl Number
Provide--information shown above for both septic and water systems
2S. OPTION TWO
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U I am applying for a building permit, and environmental health has required an
evaluation of the following:
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LJ Existing Septic System (Fee: $62)
• Age of System
Number of Bedrooms
Name of Last Owner
Is house currently occupied?
-yes— --go—
Attach pumper-s report, dated within last 3 years, stating whether the system was pumped, tite 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.
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u Reserve Area for Future System Repair (Fee: $62)
Two properly excavated pits are 4 It deep must be ready for inspection by the department.
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LJ Both (Fee: $62)
Provide information shown above for both septic system and reserve area
2C. OPTION THREE
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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:
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H \0N-SITEIFHRFVIFW.W Revi Bien t/Ov!?�
PART 3: PLOT PLAN
Use this space to draw a detailed plot plan, or attach one to this application. A detailed plot planlis one that
shows the precise location of the test holes, existing septic systems, dimensions of the property, anb location-of any
wells, roads, or other buildings on the property.
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PART 4: AUTHORIZATION
APPLICANT /
DATE �p
If:\ON-SITEIEffRF.VIFW.W
Revision t�1/n?�a�
PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY
5A. DETERMINATION OF APPLICABLE STANDARDS
The primary drainfield area must meet the following standards:
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l--I Meet current standards u
Standard marine system
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U No overt failure n
U Not applicable.
The reserve drainfield area must have site characteristics that could support a septic system th t would meet the
following standards:
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U Meet current standards. U
Meet marine repair standards.
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U Meet marine expansion standards. U
Not applicable.
5B. WATER SYSTEM
YES NO INDIVIDUAL WATER SYSTEM
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U A eater sample was taken by health department staff and analyzed. Total coliform batter a were
determined to be absent. Laboratory results are attached to this report.
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U The well cap was inspected. The sanitary seal appears satisfactory.
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yr U The well casing was inspected. The casing projected above ground and ground was sloped way from the
casing.
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U The cell site was inspected. No septic systems, chemical storage facilities, manure pit s, animal feed
lots, or other obvious sources of contamination were located within a 100 foot radius of the well.
PUBLIC WATER SYSTEM
n n
U LJ Records indicate water sampling requirements are being satisfied.
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LJ U Records indicate the Water Facility Inventory form is current.
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LJ U Department files contain no information indicating the system is out of compliance with state or local
water system requirements.
5C. SEPTIC SYSTEM
YES NO
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U The septic tank was inspected by a certified septic tank pumper within the past 3 years arp found to be
in satisfactory condition. A pumper.-s evaluation is attached to this report.
KY U Records for this property contain a septic permit, design (if required), final inspection 6pproval, and
r as-built approval.
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U The drainfield site was inspected, and appears consistent with recorded documents.
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LJ The drainfield area appears to be maintained in an acceptable manner.
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U U The drainfield area (the area where the drainfield is assumed to be located based on offic¢ records
and/or observed site conditons) appears to be maintained in an acceptable manner.
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U U The drainfield area (the area where the drainfield is assumed to be located based on offic records
and/or observed site conditons) show no indication of overt failure at the time of inspect on.
R.\ON-SITC\FRRSVIEW.I✓ P,e vi si on dal/nJ/4C.
5D. SOIL CONDITIONS
TEST HOLE #1 TEST HOLE #2 I TEST HOLE 43
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Depth of root pen. : I Depth of root pen. : Depth of root pe*. :
Depth to restr. layer D th to restr. layer Depth to restr. layer
Soil Type: Soil e: Soil Type:
Vertical Separation:A Vertical eparat' n:A I Vertical Separati!ron:A
Curtain drainable? IN/NA) : _
Slope (%) :
Shoreline? ( N) :
Minimum 1 size:$
Design level:
A Vertical separation is the de of unsaturated, original, undisturbed sot of Types 2-6 that exists between
the bottom of the subsurfac absorption system and a restrictive layer or t watertable. Vertical separation
for purposes of desi nati designer level will be calculated by the health artment based on 12-inch deep
5E. OTHER NOTES AND CO ENTS
I1:\ON 3trclMtRF,VjrW.lJ Rr vi si on',O]/Ol!96
PART 6: HEALTH DEPARTMENT DETERMINATION - OFFICIAL USE IONLy
6A. PRIMARY DRAINFIELD SYSTEM
The primary drainfield area was inspected by staff and pertinent record. were
reeviewed. The following determination has been made:
The system appeared to be functioning adequately at the time of ins ection and
and meets current design standards.
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tJ The system appeared to be functioning adequately at the time of inspection.
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u Not applicable.
Comments:
6S. RESERVE DRRAINFIELD 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:
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I I Current standards.
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LJ Marine expansion standards.
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U Marine repair standards, Treatment Standard
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" Not applicable.
Comments:
6C. WATER SYSTEM
The water system was evaluated by staff the following determination has been made:
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 found to be absent.
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1--� The water source is a public water system that appears to be in subs antial
compliance with applicable regulations.
Comments:
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Findings and determinations of this review reflect observed conditions as they existed on the day the e......vatu ion 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.
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INSPECTOR
DATE
If:ION-SITFl R,11REVIFW.IV vision 01/r7196
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