The URL can be used to link to this page

Home My WebLink AboutCRT2001-00198 - CRT Application - 10/18/2001 MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFIC E BOX 1666 SIIELTON WA 98584 (3 ) 427-9670 APPLICATION FOR ENVIRONMENTAL HEALTH REWX 427-7798 Receipt No: J (o 13 OCT �OV Date of Payment: of 18 �� Septic Water Review ) : Both ($1005100) : Property Evaluation (S85+$50/Hr) : INSTRUCTIONS „T/f _z'(00 I_� �) FS' 1. An application is considered complete when the,fee is paid. Parts 1-4 of the application form are ccnipleted. (assistance will be provided upon request for completing Part Teo). 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 mare than I hour of work. the department will charge the applicant an a ditional hourly rate of S50/hour as set forth by the Mason County Board of health. PART 1: APPLICANT/PARCEL IDENTIFICATION NAME OF APPLICANT /.fJ0101 114eq TELEPHONE SITE/HOUSE ADDRESS MAILING ADDRESS U5/��LTO�/J ' StaLC tip ACREAGE ASSESSOR'S PARCEL NUMBER LEGAL PROPERTY DESCRIPTION SUBDIVISION (If Applicable) DIV _ BLK LOT 1-:7 DIRECTIONS FOR LOCATING SITE Sketch location of property in this space. H:\ON-SITE\EHREVIEW.W Revisi�n 12/17/97 PART 2: PURPOSE OF APPLICATION N I am applying for a bank loan and the bank has asked for an evaluation o the fol l owj.ctg� � Septic System (Fee: $85) Age of System Age of House 7 • Number of Bedrooms Name of Last Owner Is house currently occupied? s '—Ro • Attach pumper's report• dated within.mlast 3 years• stating whether the system was pumped, Lhe size and condition of the tank. and the condition of the baffles. n h__m Water System (Fee: $85) • Number of service connections on water system If public water system: Name of Sys-Eem n u Both (Fee: $100) WFI Number • Provide information shown above for both septic and water systems 2B- OPTION TWO El I am applying for a building permit and environmental health has requir an evaluation of the following: . 4 n h__h Existing Septic System (Fee: $85) Age of System Number of Bedrooms Name of Last Owner Is house currently occupied? des— --To— Attach pumper's report• dated within last 3 years, stating whether the system was pumped, he 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 fo new On-Site Sewage DisposalPermit. If the original septic permit cannot be located and system more than 5 years old, submit s gned as-built drawing from certified designer or professional engineer. n A L-J 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 u Both (Fee: $85) Provide information shown above for both septic system and reserve area H:\ON-SITE\EHREVIEW.W Revision 12/17/97 2C. OPTION THREEl E 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 s 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. 1, PART 4: AUTHORIZATIO APPLICANT DATE d H:\oN-SITE\EHREVIEN.N Revisi3n 12/17/97 PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE 014LY 5A. DETERMINATION OF APPLICABLE STANDARDS The primary drainfield area must meet the following standards: n n LJ Meet current standards LJ Standard marine system n / No overt failure LJ Not applicable. The reserve drainfield area must have site characteristics that could support a septic sys em that would meet th following standards: n n LJ Meet current standards. L' Meet marine repair standards. n u Meet marine expansion standards. Not applicable. 5B. WATER SYSTEM YES L00 INDIVIDUAL WATER SYSTEM n 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 are attached to this report. n n u u 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 loped away from the casing. n n u u The well site was inspected. No septic systems. chemical storage facilities, man re piles. animal feet lots. or other obvious sources of contamination were located within a 100 foot ra ius of the well. PUDLIC WATER SYSTEM n n u u Records indicate water sampling requirements are being satisfied. n r-i u u Records indicate the Water Facility Inventory form is current. n n u u Department files contain no information indicating the system is out of complianca with state or local water system requirements. 5C. SEPTIC SYSTEM YES NO 1p1' n �y LJ The septic tank was inspected by a certified septic tank pun()er within the past 3 years and found to h< in satisfactory condition. A pLrper's evaluation is attached to this report. n u Records for this property contain a septic permit, design (if required), final inspection approval. an, as-built approval. �( n JAi Li The drainfield site was inspected. and appears consistent with recorded docunents. n u The drainfield area appears to be maintained in an acceptable manner. n Li The drainfield area (the area where the drainfield is assured to be located based on office records and/or observed site conditios) appears to be maintained in an acceptable manner. n (� u The drainfield area (the area where the drainfield is assured to he located based on office records and/or observed site conditins) show no indication of overt failure at the time of inspection. H:\ON-SITE\EHREVIEW.W Revision 12/17/97 5D. SOIL CONDITIONS TEST HOLE 11 TEST HOLE #Z TEST HOLE 13 Depth to restr. layer Depth to restr. la r Depth to restr. layer _ Soil Type: oil Type: _ Soil Type; N SCORE Soil Type: Soil Depth: Slope: Parcel Size: Distance to ' horeline: 5E. OTHER NOTES AND COM S H:\ON-SITE\EHREVIEW.W Revisi 12/17/97 PART 6: HEALTH DEPARTMENT DETERMINATION - OFFICIAL USE O LY y 6A. PRIMARY DRAINFIELD SYSTEM The primary drainfield area was inspected by staff and pertinent records w re reviewed. The following determination was made: The system appeared to be functioning adequately at the time of inspection and and meets current design standards. XThe system appeared to be functioning adequately at the time of inspection. El 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: El Current standards. Marine expansion standards. Marine repair standards. Treatment Standard Not applicable. Comments: 6C. WATER SYSTEM The water system was evaluated by staff and the following determination w3s made: The water source consists of an individual well that appears to be a satisfactory source i orm bactera were potable ie for found single befamily absentresidence. The water was sampled, and eol El The water source is a public water system that appears to be in substantial compliance with applicable regulations. Comments: m: ,:.:: ..... deterions re va uation was Findings and determinations of this review reflect observed conditions as they existed on the ay e 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 r�' tJ DATE ID H.\014-SITE\EHREVIEWN Revision 12/17/97