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Home My WebLink AboutCRT2005-00032 - CRT Application - 3/11/2005 � SON COUNTY DEPARTMENT OF HEALTH SERVICE---<< 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: hft://www.co.mason.wa.us FAX:(360)427-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW PERMIT NUMBER PAYMENT INFORMATION TYPE OF RE VIE CRT Receipt Number):X ,� Sep"d Water $250 ❑ Cash ❑ Septic $150 ❑ Check ❑ Water $150 �_ll-0� El Property Evaluation $150- Date of Payment ❑ Resample $18 lab fee Important Notice: Findings &determinations of this review reflect observed conditions as t ey exist 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 eval 4ated ****FILI,OUT APPLICATION COMPLETELY AND ACCURATELY**** An application is considered complete when the fee is paid,parts 1,2, and 3 of this applicati n 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 t34t eARA- N V-5f)l-3, Name of Applicant Rt tD ReLL-e- rAr— Telephone3(EC Mailing Address of Applicant Pp g City beLFrrAll?-- State WA Zip 12-digit Tax Parcel No. 2 �2 3 1 1 -- 7- -- 3 Site Address :3 2V Pit-IC C k,04t> Brief Legal Description So Ry al Driving Directions " eel I -m i;z. TAKE lei tr O&v B At -TAKo A r- 01.D AM P)c X;, t Lj oK T n t l L% 1i NCCKA--- l 6 N'i t 5 wi.q t P R046 'r'o Abt> A-> RtExN,I- (5kA Fp ARlvE=z0aL-( L-01YU SDIO Page 1 of 4 F.3, 477�9&iiee cwe-- ` czs htztL,-r- , pL_,4q-7- ^I-p .(�v9j p i32-POT- PART 2: TYPE OF REVIEW ❑ Septic System • Age of system /0 • Age of house 16 ytir • Number of bedrooms • Nanie of last owner • Is house currently occupied?0 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 • 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. a S VA PART 3: PLOT PLAN Use the space below to draw a detailed plot plan, or attach a detailed plot plan to this al plication. The plot plan should include the following: North Arrow, Location of Test Holes, Location of Existing Septic System, Dimensions of Property, Location of any Drinking Waster Sources (wells, springs,etc.)Roads,Easements, Surface Water, and Buildings on the property. LOT SIZE a' X Acres COMPASS r Applicant's Signature: Gate — --,Q ,57 Page 2 of 4 PART 4: HEALTH DEPARTMENT FINDINGS—OFFICIAL USE ONLY Septic System Yes No 0 The septic tank was inspected by a certified septic tank pumper within the last years and was found to be in satisfactory condition. A pumpers report is attached. Wr ❑ Records for this property contain a septic permit, design, final approval and 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 Water System ❑ A water sample was taken by health department staff and analyzed. Total colift 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 grot nd was sloped 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. Yes No Public Wa r System ❑ ❑ Records indicate water-samplin require nts are being satisfied. ❑ ❑ Records indicate the Water Facility entory for is current. ❑ ❑ Department files contain water stem design and letter of approval. Soil Conditions Test Hole #1 Test Hole#2 Test Hole#3 Soil Type: oil Type: Type- Restrictive layer: Restrictive layer: Restrictive layer: Slope: Slope: Slope: Distance to Shoreline: Distance to Shoreline: Distance to Shorelin Page 3 of 4 Page 3 of 4 PART 5: HEALTH DEPARTMENT OBSERVATIONS—FOR OFFICIAL USE ONLY Primary Drainfield Yes No �G ❑ The system appears to be functioning adequately at the time of the inspection. (Oily « applicable if system has been in use on a regular basis for the last 6 months.) C Sanitary survey? C Pass C Fail ❑ Suspect C Not applicable Water System `Yes No t ❑ The water source consists of an individual well that appears to be a satisfactory 111 source of potable water for a single-family residence. The water was sampled an 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 >rPass ❑ Fail PART 6: COMMENTS INSECTOR &akkI&A Nw v DATE 3 (7 p5 Important Notice: Findings determinations of this review reflect observed conditions as th exist on the day the evaluation was preformed. Absolutely no claim is made by this office, expresse I or implied concerning the future success, failure or permit approval of the system and site evaltuded. Page 4 of 4