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Home My WebLink AboutCRT2001-00210 - CRT Application - 11/19/2001 MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTON, WA 98584 (360) 4 --900 APPLICATION FOR ENVIRONMENTAL HEALTH RNr� , �1 tJ 10 N M uu NOV 19 2001 Receipt NO: I Date of Payment: � - - I HEALTH SERVICES Septic or Water Review ($85) I Both 0) : i I Property Evaluation ($85+$50/Hr) : INSTRUCTIONS n „�. � �� 1. An application is considered coaplete when the fee is paid, Parts 4 of the application form are completed. (assistance will be provided upon request for coapletire Part Two), the necessary paperwork is attached, and required soil evaluation holes have been excavated. 2. After a coapleted application is received, staff will inspect the property and provide the applicant with a written report. 3. If the site review requires more than 1 hour of work, the department will charge the applicant an additional hourly rate of S50/hour as set forth by the Masan County Board of Health. PART 1: APPLICANT/PARCEL IDENTIIFICATION NAME OF APPLICANT 2" C 164r- I rf:3�frv1cz✓I TELEPHONE SITE/HOUSE ADDRESS .� 4-$D m f�L'K PYzt•h�e lu 1 �� FAX �13� -Glv� MARLING ADDRESS LA,44 17fS 4- ACREAGE City State Lip ASSESSOR'S PARCEL NUMBER 3 1 - - �i V4 LEGAL PROPERTY DESCRIPTION SUBDIVISION (if Applicable) C n DIV BLR -- 1LOT ?a `/ DIRECTIONS FOR L NG SITE {`u T tsv7�1.'� PaC'3! 'C 1"�C�'l A �''e "b�•'� - • pM, a Y (,1E'LGK -------------------- M � Sketc location of propert \l I r I I I N:%ON-STTS(FH9EVIEN.w aevIalca 2126199 page 1 PART 2: PURPOSE OF APPLICATION A. OPTION ONE I am applying for a bank loan and the bank has asked for an evaluation Of the following: • Septic System (Fee: $85) % • Age of System �� lR • Age of House • Number of Bedroom • Name of Last Owner • Is house currently occupied? .;�/� '�— ilo • Attach puaper'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. n LJ Water System (Fee: $85) • Number of service connections on water system • If public water system: Name o System r-1 WFI N r LJ Both (Fee: $100) • Provide information shown above for both septic and water system 2B. OPTION TWO UI am applying for a building permit and environmental health has required an evaluation of the following: n L-I Existing Septic System (Fee: $85) • Age of System • Number of Bedroom • Name of Last Owner • Is house currently occupied? Yes No • Attach puiper'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 for 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: $85) Two properly excavated pits are 4 ft deep must be ready for inspection by the department. n LJ Both (Fee: $85) Provide information shown above for both septic system and reserve area N:10N-S17Elt2OtEVZEW.w Revfalon 2/26/99 page 2 sC OPTION THREE r-1 tJ I am interested in knowing in general terms the suitability of a parcel for septic system placement. (Fee: $85 base, plus $50/hour after first hour) Describe the intended use of the property and the reason for requesting the review: PART 3: PLOT PLAN Use this space to draw a detailed plot plan, or attach one to this application. A detailed plot plan is 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 bulldings on the property. I I I I I I I I I I I I I I fe" I I � � I i � I I I I I I I _ I I I I I PART 4: AUTHORIZATION APPLICANT ', fE DATE U/ R:\01I-SZ7EXEEREV1Ew.w Revlalon 2126199 Pa9e 3 PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY 5A. DETERMINATION OF APPLICABLE STANDARDS The primary dreinfield area must meet the following standards: n n U Meet current standards U Standard marine system n No overt failure U Not applicable. The reserve dreinfield area oust have site characteristics that could support a septic system that would meet the following standards: n n U Meet current standards. U Meet marine repair standards. n U Meet marine expansion standards. Not applicable. 58. WATER SYSTEM YES NO INDIVIDUAL WATER SYSTEM n n U u A water sample was taken by health department staff and analyzed. Total coliform bacteria were determined to be absent. Laboratory results.ere attached to this report. n n LJ LJ The well cap was inspected. The sanitary seal appears satisfactory. n n U U The well casing was inspected. The casing projected above ground and ground was sloped away from the casing. n n LJ LJ The well site was inspected. No septic systems, chemical storage facilities, manure piles, animal feed tots, or other obvious sources of contamination were located within a 100 foot radius of the well. PUBLIC WATER SYSTEM n n LJ LJ Records indicate water sampling requirements are being satisfied. n n lu LJ Records indicate the Water facility inventory form is current. n n U LJ Department files contain water system design and letter of approval? 5C. SEPTIC SYSTEM YES NO r� n 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 pumper's evaluation is attached to this report. n U Records for this property contain a septic permit, design (if required), final inspection approval, and / as-built approval. rpi n U The dreinfield site was inspected, and appears consistent with recorded documents. n rA! U The drainfield area appears to be maintained in an acceptable roamer. n U The dreinfield area (the area where the drainfield is assumed to be located based on office records / and/or observed site conditons) appears to be maintained in an acceptable roamer. n 4°l U The dreinfield area (the area where the drainfield is assumed to be located based on office records and/or observed site conditios) show no indication of overt failure at the time of inspection. H:%W-SZTE%EHREVZEW.w Revision 3/I6/99 Page 4 5D. SOIL CONDITIONS TEST HOLE #1 TEST HOLE #2 TEST HOLE #3 Depth to restr. layer Depth to restr. laye Depth to restr. layer Soil Type: Soil Type: Soil Type: F NDING SCORE Soil Type: Soil Depth\// Slope: Parcel Siz Distance t o ,6horeline: \\ SE. OTHER NOTES AND COMMEOTS R:\ON-SITEVEEREVxE .N ReVisia 2/26199 ps9e 5 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 was made: 1—I The system appeared to be functioning adequately at the time of inspection and and meets current design standards. ' The system appeared to be functioning adequately at the time of inspection. u Not applicable. Comments• GJe d ( ! � i� { {7rw brlK o t{rfc� sii«� ws 68. RESERVE DRAINFIELD 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: LJ Current standards. f—1 l I Marine expansion standards. 1-1 u Marine repair standards, Treatment Standard 9 Not applicable. Comments: 6C. WATER SYSTEM The water system was evaluated by staff and the following determination was made: f l 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. n tJ The water source is a public water system that appears to be in substantial compliance with applicable regulations. Comments: .................................................................. ........................................................ ..................... ................................................................................................................................................... ................................................................................... . 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, concerning future success or failure of the systems and sites evaluated. Resource land and critical area checklist nay be required by Department of Coanunity Development prior to issuance of developmental permit. 1 INSPECTOR l.'li �+M DATE ' I 7- —7 O N:\ON-SITE\ENREVIEN.N Revision 7/26/99 Page 6