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Home My WebLink AboutCRT97-0141 - CRT Application - 8/26/1997 , 1 . MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTO WA 98584 (3 0) 427-9670 FAX 42 7-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW ME 5 ROWE Receipt No: `V Date of Payment: AUGV{7 Septic or water Review ($62) : PERMIT ASSISTANCE CENTER I Both ($loo) : �� Property Evaluation ($62+$45/Hr) : INSTRiTCTIUNS 0�� o le�-4 _ i q I 1. An application is considered complete when the fee is paid, Parts 1-4 of the application form are cDWteted. (assistance will be provided upon request for completing Part Two), the necessary paperwork is attached, and 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 a ditional hourly rate of $40/hour as set forth by the Mason County Board of Health. PART 1 APPLLICANT/PAR EL DC4IFICATION c I a NAME OF APPLICANT �TFi=� ;7Ci G L—//. U'//1WAI it - TEL HO,dE —76 46 h �� SITE/HOUSE ADDRESS `L�' D Q 6Y .�G.P LOUiO. MAILING ADDRESS /P rj �` - ACREAGE V iry* nn � a e i�ASSESSOR'S PARCEL NUMBER oC -�3 - 0 O 0-3 LEGAL PROPERTY DESCRIPTION �yCP. D 'O W qJ�� SUBDIVISION (If Applicable) DIV _ BLK/ LOT S OR DIRECTION LO TING SITE 'oe v/ ,. T r Sketch location of property in this's ce NT �J L �� z1 0 I"� � � x:%0N-slrelk+REvW.W -i' Revision 01107196 PART 2: PURPOSE OF APPLICATION 2A. OPTION ONE am applying for a bank loan and the bank has asked for an evaluation of the ollll/owing: S�6eptic System (Fee: S62) • Age of System • Age of House � — 4 • Number of Bedrooms Z • Name of Last Owner f Is house currently occupied? -Tes • Attach puiperms report, dated Within last 3 years, statin Whether the sy en was pumped, the size and condition of the tank, and the condition of the baffles � ,,,? XNater System (Fee: $62) /l Number of service connections on Water system If public Water system: ame Ot System n um er U Both (Fee: $100) • Provide information shown above for both septic and water systems 213. OPTION TWO u I am applying for a building permit, and environmental health has required an evaluation of the following: n U Existing Septic System (Fee: S62) • Age of System Number of Bedrooms • Name of Last owner • Is house currently occupied? eti� �!o - 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 f r 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 lJ Reserve Area for Future System Repair (Fee: S62)Two properly excavated pits are 4 ft deep must be ready for inspection by the department. _ r-T LJ Both (Fee: $62) Provide information shown above for both septic system and reserve area 2C. OPTION THREE I—I U 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: If:\ON-SITE\ENREVIEW.W Revis on 01107196 PART 3: PLOT PLAN Use this space to draw a detailed plot plan, or attach one to this application. A detail d plot plan s one that shows the precise location of the test holes, existing septic systems, dimensions of the property, and location of any wells, roads, or other buildings on the property. I I I I I � I I I I I I I I I I � I I 6-r I I I I i I I I I I I I I I PART 4: AUTHORIZATION l APPLICANT DATE 71k7- 1l:%ON-SITEIEHREVIEW.W Revisi n 01107196 PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY SA. DETERMINATION OF APPLICABLE STANDARDS The primary drainfield area must meet the following standards: n n LJ Meet current standards U Standard marine system r-1 No overt failure LJ Not applicable. The reserve drainfield area must have site characteristics that could support a septic system that would meet the following standards: n n LJ Meet current standards. u Meet marine repair standards. n U Meet marine expansion standards. Not applicable. 5B. WATER SYSTEM NO INDIVIDUAL WATER SYSTEM I__I A Amer sample was taken by health department staff and analyzed. Total ccliform bacteria were determilw to be absent. Laboratory results are attached to this report. n LJ The well cap was inspected. The sanitary seal appears satisfactory. n U The well casing was inspected. The casing projected above ground and ground was sloped away from the casing. n U The well site Was inspected. No septic systems, chemical storage facilities, manure pi es, animal feed Lots, or other obvious sources of contamination were located within a 100 foot radius al the well. PUBLIC WATER SYSTEM UU Records sampling wants are being satisfied. n n LJ LJ Records indicate ater Facility ory form is current. n n u LJ D rtment files contain no information indicating t ystem is out of compHance with state or local water system requirements. 5C. SEPTIC SYSTEM YES NO kX n 1°l U The septic tank was inspected by a certified septic tank punper within the past 3 years and found to be in satisfactory condition. A punper-s evaluation is attached to this report. n L X Records for this property contain a septic permit, design (if required), final inspection approval, and as-built approval. n U The drainfield site was inspected, and appears consistent with recorded documents. n XKx U The drainfield area appears to be maintained in an acceptable manner. I�f n Yam` LJ The drainfield area (the area where the drainfield is assumed to be located based on of ice records and/or observed site conditons) appears to be maintained in an acceptable manner. vf1 n la LJ The drainfield area (the area where the drainfield is assumed to be located based on ofi ice records and/or observed site conditons) show no indication of overt failure at the time of inspection. H:10N-SITEIEHREVIEW.W Revis on 01107196 5D. SOIL CONDITIONS - TEST HOLE #1 TEST HOLE #2 I TEST HOi.E #3 - E I _ -ZI - Depth of root pen. : Depth of root pen. : _ i Depth of root pen. : _ Depth to restr. layer Depth to restr. yer _ i Depth to restr. layer _ Soil Type: oil Type: Soil Type: Vertical Separation:A Ve tical Se aration:A .Vertical Separat on:A curtain drai le? (Y/N/NA) : Slope (U : Shorelin . (YIN) : Minimu lot size:$ Desi er level: Vertical separation is the epth of unsaturated, original undisturbed soil of Types 2-6 that exists between the bottom of the subsurf a absorption system and a restr Live layer or the watertable. Vert kat separation for r ses of desi nat'n desi ner level will be calculat by the health departmcnt based on a 12-inch deep SE. OTHER NOTES AND CO NTS II:ION-SITE\EHREVIEW.W Revis on 01107196 PART 6: HEALTH DEPARTMENT DETERMINATION - OFFICIAL USE ONLY 6A. PRIMARY DRAINFIELD SYSTEM The primary drainfield area was inspected by staff and pertinent records were reviewed. The following determination has been made: n u The system appeared to be functioning adequately at the tine of inspection and �( and meets current design standards. SAl The system appeared to be functioning adequately at the tine of inspection. n U Not applicable. Comments: a. A-LO 'Poem o d 1v w} +LtR. 11 Na e-4Jwd di Sr WiNQ�Yc..�•4.iC9..• 6B. RESERVE DRAINFIELD AREA T' 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: I—I lJ Current standards. n u Marine expansion standards. I-1 u Marine repair standards, Treatment Standard 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 satisfactory source of potable water for a single family residence. The water was sampled, and coliform bacteria were found to be absent. n u The water source is a public water system that appears to be in substantial compliance with applicable regulations. Comments; or 1 d 1 Sa C � O ...................................................................................................................... ......................................................................................................................................................... .................... Findings and determinations of this review reflect observed conditions as they existed on the day the evaluation was performed. Absolutely no claim is made by this office, either expressed or implied, concern`ng future success or failure of the systems and sites evaluated. j Resource land and critical area checklist may be required by Department of Community Development prior to issuance of developmental permit. INSPECTOR DATE H:ION-SITE\EHREVIEW.W RII!Ii n 02107196