HomeMy WebLinkAboutSPH95-0034 - SPL Application - 4/10/1995 MASON COUNTY DEPARTMENT OF no
APR 10 1 POST OFFICE BOX 1666
SHELTON, WA 98584
9670
F� TH SERVICES (FA 427-8425
1� SH FA 427-8425
APPLICATION F ORT PLAT EVALUATION
Receipt No: G d S
INSTRUCTIONS 5jP-H C _ Date of Payment:
1. An application is considered complete when the fee is paid and the following elements have been addressed:
• Parts 1 and 2 of the application form must be completed.
• One properly excavated backhoe pit per proposed parcel muat 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 It deep shelf must slope up to th ground _
surface for easy ingress and egress.
• A scaled plot plan must be attached to the application. The scaled plot plan must show the precise Location
of the test holes, dimensions of the property, and location of any existing or proposed wells, roads or
buildings within 100 It 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 co lotion
of this report, an hourly rate of S37/hour as set forth by the Mason County Hoard of Health may be charged to
the applicant. Revised 09/01/92
PART 1: APPLICANT/PARCEL IDENTIFICATION
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• NAME OF APPLICANT mARYANS SI-LVCTRST`Er.I a • TELEPHONE
A( Z.O(o Z7- 6S8 j
• MAILING ADDRESS S,N, 41 514Hboy, OOD ,BEND
,5/4<0N u/A 9B58
CYt, Z1v
• ASSESSOR'S PARCEL NUMBER 3 Z 3 4 - 7 5 - O O o 8 Q
• LEGAL PROPERTY DESCRIPTION //V T_#6 S% GF THE OF SRC, 34 G( IJ 3wul n�
—700$/ —q10082- — 'Amn
• LOT SIZES (ACRES OR SQ FT) Z• 0Z 4C. /•00 AG. AC. •OO Re .
Lot 1 Lot 3 LIoIIt 3 Let 4
• DIRECTIONS FOR LOCATING SITE FjZ LqT1 14C LO/V foul y3 D
sow L Tu c CO 1 z t Tv C/9Tj/5 L/i £
O. t To /n TdasPcTON, TOQW GE-Fr o C,c o, 2. rel) +
TO /*�LUE F[RaS. f 4 .CU Src
PART 2: INTENDED USE OF PARCEL
• INTENDED USE OF PROPERTY (Check One) :
Single family residence Multi-family residence
Other, specify:
• WATER SOURCE FOR PARCELS (Check One) :
91 Individual wells Community well
M-1
Short Plat EvaltatiOn
PART 3: HEALTH DEPARTMENT REVIEW (OFFICIAL USE ONLY)
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SOIL LOGS AND SITE CHARACTERISTICS
LOT LOT #/6 LOT
Test Pit A ✓ Test Pit A Test Pit A Test Pit A
,of C2 L)u �": 0 -V L uavw,/SituD Ic7*0Z)
6-- 26 5,0.t&Lck�m YF'-25� Z L)L-1 PA
r-1L)kSqAAbi6r&ue1
C T-4 PC i A)
Depth of root pen.: 20 Depth of mot pen.: Depth of mot pan.: Depth of root pen.:
Depth of mottling: Depth of mottling: Depth of mottling: Depth of mottling:
Depth to rest. layer: Depth to rest. layer: d4 X' Depth to rest. layer:3F Depth to rest. layer: 21
Soil type (USDA): Soil type (USDA): Soil type (USDA): S Soil type (USDA): 3
Test Pit A Test Pit B Test Pit B Test Pit B
Depth of root pan Depth of mot pen.: Depth of mot pen.: — Depth of root pen.:
Depth of mottling: Depth of mottling: Depth of mottling: Depth of mottling:
Depth to rest. layer: Depth to rest. layer: Depth to rest. layer: Depth to rest. la,,er:
Soil type (USDA): Soil type (USDA): Soil type (USDA): — Soil type (USDA):
[Li- drain needed? curtain drain needed? curtain drain needed] N curtain drain n..ed?
Slope (1k): Slope (%): Slope (%): 0 Slope (%):
Shoreline? (Y/N): Shoreline? (Y/N): Shoreline? (Y/N): Shoreline? (YIN)2
Kini-,,- lot size- minimum lot size:^ Y Minimum lot size:- Minimum lot size:
Minimum lot size applies to new Subdivisions and is defined as the minimum allowable land area per residence or residen-
tial equivalent (450 gallons per day).
0014KENTS
Short Plat Rval cation
PART 4: HEALTH DEPARTMENT REVIEW SUMMARY (COMMUNITY DEVELOP USE)
MEETS HEALTH CODE
After examining lot size, proposed water source, and soil type, it 's the de-
termination of Mason County Department of Health Services that eacl proposed
parcel can support an on-site sewage disposal system meeting the rejuirements
of state and local regulations.
® DOES NOT MEET HEALTH CODE
After examining lot size, proposed water source, and soil type, it s the de-
termination of Mason County Department of Health Services that eac 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) :
® HOLD APPROVAL UNTIL FURTHER ACTIONS ARE TAKEN BY APPLICANT
After examining lot size, proposed water source, and soil type, it s 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 until the following conditions are met:
ition(a) z ired prior to approval have been met by the applicant.
9 lth Official Date
PART 5: REVIEWER SIGNATURE
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He�7 Official `Y' Date