HomeMy WebLinkAboutCRT93-0048 - SWG Onsite Survey - 3/3/1993 • t
MASON COUNTY
DEPARTMENT of HEALTH SERVICES
Mason County Bldg. III 426 W.Cedar
P.O. Box 1666 Shelton,Washington 98584
(206)427-9670 • Belfair.275-4467 '
Seattle:464-6968 • Other: 1-800-562-5628
environmental health personal health water quality
SANITARY SURVEY
[) WATER ONLY $40. 00 p9 SEWAGE ONLY $50.00 [) WATER AND SEWAGE $68.00
CHECKS PAYABLE TO: MASON COUNTY TREASURER SUR# CC3s�-' !Ms
FEE RECEIPT #C1J4-7
APPLICANT'S INFORMATION
PARCEL NUMBER _3 Z Ijjy - 5-0 n - P.YYI 09 C* D y DATE
LEGAL DESCRIPTION 4 o FS O p'r /
OWNER'S NAME _ a It Uowun APPLICANT NAME r br,"
MAILING ADDRESS -RD &on 17,34 MAILING ADDRESS � O. /jox 7L9 - SDI L •i
I.Vv .,F wA - c(8SI S
TELEPHONE NUMBER !E-?2- 3f Z 8 nn T r,TELEPHONE NUMBER Ct 2 6 Z- q
MAIL INFORMATION TO: A Oki - SSa fi
P-0- 6o,( -72R VA- 9�say
(STREET) p(CITY) (STATE) (ZIP)
DIRECTIONS TrrOII,, THE7 SITE//: I{ AJn , rtyAt a {MCFwe, P-cv:•e Kj — n 1
NG ItL� bn - (�5/n f - 1 9/O W� C'0��-f �:n�"/c� O.� ✓✓i[ rL 1..�..r Pr—,,. /Z
V A(e low e..-I�i/ " r%�bei�o Ln cC/P� �'ZY80 YVI c Er sc,. P.w^ti R d 1
REQUIRED FOR SEWAGE SURVEY
AGE OF SYSTEM -I +-� PUMPERS REPORT ATTACFW
AGE OF HOUSE YES ( NO
LAST OWNER SIv l(an (�nit�acf on
HOUSE OCCUPIED YES N NO 11
NUMBER OF BEDROOMS,-3
REQUIRED FOR WATER SURVEY
WATER SUPPLY (CIRCLE) 49 SPRING
WATER SYSTEM TYP��{y (CIRCLE) INDIV. UBL
NAME OF SYSTEM nnbCaonbew L4A.ce
LOCATION OF WELL RcttnhVQ
APPLICANT'S SIGNATURE ��J �-✓li DATE 3(3193
S-18 ern>r? - 'ycl2d
SUR#
FOR HEALTH DEPARTMENT USE ONLY
SEWAGE DISPOSAL SYSTEM
RECORDS FOR THIS PROPERTY INDICATE THAT THE SYSTEM WAS INSTALLED
ON 6a -3 SG AND CONSISTS OF A (SEPTIC TANS) (CESSPOOL) (DRYWELL)
AND z SQUARE FEET OF DRAINFIELD.
[] RECORDS HAVE BEEN SEARCHED AND ARE INCOMPLETE OR CAN NOT BE LOCATED.
�
�([J THE SEPTIC TANK WAS PUMPED ON — Z4�- q (COPY OF PUMPERS REPORT)
VVV THE RECORDED AREA OF THE DRAINFIELD WAS INSPECTED AND NO EVIDENCE FAIL
AS IDENTIFIED.
[] THE ACCESSIBLE AREA'S AVAILABLE FOR A DRAINFIELD SURROUNDING THE HOUSE
WERE INSPECTED AND NO EVIDENCE OF FAILURE WAS IDENTIFIED.
G
WATER SUPPLY bI J�� ��•Q�
WATER SAMPLE WAS TAKEN BY HEALTH DEPARTMENT STAFF AND DETERMINED TO '
B TISFACTORY\UNSATISFACTORY FOR TOTAL C=ZATER
RIA.
[] THE WATER PPLY TO THIS RESIDENCE IS A CYSTEM AND RECORDS
INDICATE THA SYSTEM IS IN COMPL NOT IN COMPLIANCE.
I.D.NO.
[] THE WELL CAP WAS INSP D F A SANITARY SEAL AND APPEARS TO BE
SATISFACTORY\UNSATISF
[] THE WELL CASING WA NSPECTED IS LOCATED ABOVE/BELOW GROUND.
I] THERE IS A PO BLE SOURCE OF CONTAMI ION LOCATED WITHIN 100 FEET OF THE
WELL.
[] THE L CASING COULD NOT BE LOCATED OR ADEQIIA Y INSPECTED.
CO S ON FINDINGS:
DISCLAIMERt THE FINDING AND OBSERVATIONS S URVEY ARE BASED
CONDITIONS AT THE TIME OF THE REVIEW. NO GII S PRESSED ON IMPLIED BY
THIS SURVEY.
ENVIRONMENTAL HEALTH SPECIALIST SIGNITURE
DATE ,
2