HomeMy WebLinkAboutSPH96-0100 - SPL Application - 4/1/1996 1K/ASON Q:,OUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SHELTON, WA 98584
(206) 427-9670
APPLICATION FOR SHORT PLAT EVALUATION FAX 427-8425
3:5-0
INSTRUCTIONS Receipt No:
--01WDate of Payment:
1. An application is considered complete when the fee is paid and the following elements have been address
• Parts 1 and 2 of the application form must be completed.
• One properly excavated backhoe pit per proposed parcel nuat be ready for inspection. Properly excavated pits
are 6 ft deep with a 4 ft deep shelf on one end of the pit. The 4 ft deep shelf moat Slope up to the round
surface for easy ingress and egress.
• A scaled plot plan must be attached to the application. The scaled plot plan must show the precise 1 eation
of the test holes,. dimensions of the property, and location of any existing or proposed wells, made,
buildings within 100 ft of the property boundaries.
2. After a completed application is received, Staff will inspect the property and provide the applicant with a
written report. If the project requires more assistance than the evaluation of four test holes and cumple Son
Of this report, an hourly rate of $37/hour as set forth by the Mason County Board of Health may be charged to
the applicant.
Revised 09 01/92
PART 1: APPLICANT/PARCEL IDENTIFICATION
• NAME OF APPLICANT L a �� ram.,c T' d- ro 4 R/ A- • TELEPHONE
0 0 - 6
• MAILING ADDRESS _ you / Wo hL E
1- s<sa� z1n
ASSESSOR'S PARCEL NUMBER 8 4_
LEGAL PROPERTY DESCRIPTION „ n S P /8/ 8 •�—
LOT SIZES (ACRES OR SQ FT) _/. 06 8 Ac I. O/0 A. Ili
LOC 1 Let 3 LOG 3 L C 4
DIRECTIONS FOR LOCATING SITE SO IPA S d,
t 3/4 m; P: . A,L (, e,. rn/des
P S MO r c J p n/oP r fy ,S a r;n �.y A erf� side
ART 2: INTENDED USE OF PARCEL
................ ...........
INTENDED USE OF PROPERTY (Check One) :
FJ�
Single family residence Multi-fami IV0 UN n
1 Other, specify:
WATER SOURCE FOR PARCELS (Check One) :21� '
Individual wells ElCommunity w'FAITH SERVIC c
Short Plat Evaluation
l
PART'3: HEA I TH DEPARTMENT REVIEW (OFFICIAL USE ONLY)
. .................................
SOIL LAGS AND SITE CHARACTERISTICS
L9r f LOT f LOT f LOT f
Test Pit A Test Pit A
Test Pit A Test Pit A
VIA( wry M�kun.
Depth of root pen.; __ Depth of root pen.: Depth of root p Depth of oot
P pen.: _
Depth of mottling: Depth of mottling: Depth of mottlin Depth mottling:
Depth to test. layer: Depth to zeal. layer: Depth to teat. la r: _ Depth to rest. layer: _
Sall type (USDA): Soil type (USDA): Soil type (USDA):
Sol type (USDA):
Test Pit B Test Pit B Test Pit B st Pit B
Dep of root pen.: -- root pen Dep of root pen.:Depth f root pen.: Depth of t _Depth of mottling: Dep of mottling: Depth of mottll Dap mottli of n
Depth to zest. layer: ___ Dep to rest. layer: Depth to teat. layer: Depth zest. layer: _-
soil type (USDA): __ 1 type (USDA): soil type ( ): Soil t e (USDA): .
curtain drain needed? Curtain drain needed? curtain rain needed?
corral¢ di ¢ needed?
Slope (i): slope (1k): slo (f): Slope (�):
Shoreline? (Y/N): Shoreline? (YIN): S orellne? (YIN): Shoreline? (YIN
iinimum lot size: C Minimum lot size:^ l Minimum lot size:
Minimum lot size:
Mlnimws lot size applies to new subdivisions and s defined as the minimum allowable land area per residence or residen-
tial equivalent (450 gallons per day).
OMMENTS ,l
A/n So l/ %8s 74 7 '/-q
J
Ebert Flat Evaluation
P�fRT'4: HEALTH DEPARTMENT REVIEW SUMMARY (COMMUNITY DEVELOPMENT USE)
ie ....:..:::::'::.................
..-.i?c8. ................................... ..........-................................. . . 3c
MEETS HEALTH COD.
After examining lot size, proposed water source, and soil type, it is the de-
termination of Mason County Department of Health Services that each proposed
parcel can support an on-site sewage disposal system meeting the requirements
of state and local regulations.
® DOES NOT MEET HEALTH CODE
After examining lot size, proposed water source, and soil type, it is the de-
termination of Mason County Department of Health Services that each proposed
parcel cannot support an on-site sewage disposal system meeting the require-
ments of state and local regulations.
This determination is based on consideration of the following factor(s) :
L
HOLD APPROVAL U9 FURTHER ACTIONS ARE TAKEN BY APPLICANT
VVV After examining lot size, proposed water source, and soil type, it is the de-
termination of Mason County Department of Health Services that each proposed
parcel cannot support an on-site sewage disposal system meeting the require-
ments of state an until the following conditions are met:
4/05/ :NOSEPTIC
IC RECORDS FOUND
D LOT#1-
EPTIC RECORDS FOUND FOR PROPOSED
ICANT WILL EITHERNEED TO PROVIDE
OF OFFICIAL SEPTIC RECORDSFOR
HOWING SOIL TYPE AND DEPTH; OR
ST HOLE ON LOT #2 AND APPLY FOR
ECTION.--G.G.
condition($) required prior to approval have been met by the applicant.
Health Official Date
?ART 5: REVIEWER S NA
Health Officia
Date