HomeMy WebLinkAboutCRT99-0002 - CRT Application - 1/8/1999 MASON AWjRE6)WrMENT OF HEALTH SERVICES
QE �T � pNCEC T POST OFFLTO E BOX
1666
SHELTON' WA 98584584
(370) 427-9670
FAAXX 42 7-7798
APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW
Receipt No:
Date of Payment: -
is Water Review ($85) :
Both ($100) :
Property Evaluation ($85+$50/Hr) :
INSTRUCTIONS -
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1. An application is considered complete when the,fee is paid, Parts 1-4 of the application form are completed.
(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 thp applicant an additional
hourly rate of f50/hour as set forth by the Mason County Board of Health. I7, 4 1 �)
PART 1: APPLICANT/PARCEL IDENTIFICATION Uj(z
NAME OF APPLICANT Ade✓« lkd6o-n TELEPHONE -��A6
SITE/HOUSE ADDRESS -2D Vm
MAILING ADDRESS
ACREAGE
city
ASSESSOR'S PARCEL NUMBER 3 Q 1) /
LEGAL PROPERTY DESCRIPTION �-TK l�-�l Gt�nbyW LQ1��
SUBDIVISION (If Applicable) DIV _ BLK T LOT _
D REC IONS FOR LOCATING SITE w
LF , N ✓+ , ✓ — Lin offr
Sketch location of property in this space.
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PART 2: PURPOSE OF APPLICATION
2A. 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 -- 1 —
• Age of House
Number of Bedrooms
Name of Last Omer 11 opSOy
Is house currently occupied?_
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Attach punper's report, dated withintlast 3 years, stating whether the system was pumped, the size and
condition of the tank, and the condition of the baffles.
M
LJ` Nater System (Fee: $85)
Number of service connections on water system
If public water system:
Name of System
u r
Both (Fee: $100)
Provide information shown above for both septic and water systems
2B. OPTION TWO
I am applying for a building permit and environmental health has required an
evaluation of the following:
M
L—t Existing Septic system (Fee: $85)
Age of System
Number of Bedrooms
Name of Last Omer
Is house currently occupied?
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• Attach purper's report, dated within last 3 years. stating whether the system was pupedh 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.
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u Reserve Area for Future System Repair (Fee: $85)
Two properly excavated pits are 4 ft deep must be ready for inspection by the department.
u Both (Fee: $85)
Provide information shown above for both septic system and reserve area
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2f OPTION THREE
❑ 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 buildings on the property.
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PART 4: AUTH I ATION
APPLICANT � DATE
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PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY
5A. DETERMINATION OF APPLICABLE STANDARDS
The primary drainfield area must meet the following standards:
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u Meet current standards u Standard marine system
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1 No overt failure u Not applicable. '.
The reserve drainfield area must have site characteristics that could support a septic system that would meet th
following standards:
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u Meet current standards. u Meet marine repair standards. ,
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u Meet marine expansion standards. Not applicable.
5B. WATER SYSTEM
Y NO INDIVIDUAL WATER SYSTEM /
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u u A water le was taken by health department staff and analysed� Total colifoma bacteria were
determined to bsent. Laboratory results are attached this report.
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u u The well cap was inspe te--.J\e sanitary seal appears satisfactory.
n n
u u The well casing was inspected. The'cWshig projected above ground and ground was sloped away from the
casing. �..,
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u u The well site was inspe ed. No septic systems, c ical storage facilities, manure piles, animal feet
lots, or other obvi sources of contamination were to ed within a 100 foot hadius of the well.
PUBLIC WATER SYSTEM
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u u Re ds indicate water sampling requirements are being satisfied.
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u Records indicate the Water Facility Inventory form is current.
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u u Department files contain no information indicating the system is out of compliance with state or local
water system requirements.
5C. SEPTIC SYSTEM
YES NO
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Yam' u The septic tank was inspected by a certified septic tank pumper within the pasti, 3 years and found to b<
in satisfactory condition. A pumper's evaluation is attached to this report.
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u Records for this property contain a septic permit, design (if required), final :inspection approval, am
as-built approval.
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u The drainfield site was inspected, and appears consistent with recorded documents.
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1Ly u The drainfield area appears to be maintained in an acceptable manner.
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u The drainfield 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 manner.
u The drainfield area (the area where the drainfield is assumed to be located based on office records
and/or observed site conditons) show no indication of overt failure at the time of inspection.
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50. SOIL CONDITIONS
TEST HOLE #1 TEST HOLE #2 TEST HOLE #3
Depth to restr. layer Depth to restr. layer _ Depth to restr. layer
Soil Type: Soil' Type: — Soil Type;
FINDING SCORE
Soil Type:
Soil Depth:
Slope:
Parcel Size:
Distance to Shoreline:
5E. OTHER NOTES AND COMENTS
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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:
❑ 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 insplection.
❑ Not applicable.
Comments:
6B. 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:
Current standards.
El Marine expansion standards.
❑ Marine repair standards, Treatment Standard
f4 Not applicable.
Comments:
6C. WATER SYSTEM
—T4Q water system was evaluated by staff and the following det -minationlwas made:
El The water e.consists of an individua-l-4eT that appears to be a
satisfactory source`s bl water—for a single family residence The water
was sampled, and colif..or-mrm a -wig were found to be absent. r
❑ The water owe is a public water system pears to be in substantial
compl' ce with applicable regulations .
Comments:
............_....w :.::.:a..........:::�:.... . .:.....:.:.... .............. .
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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 may be required by Department of Community Development prior to issuance of
developmental permit.
INSPECTOR DATE61
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