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Home My WebLink AboutCRT97-0011 - CRT Application - 1/31/1997 1 S MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTON WA 98584 (36) 427-9670 FAX 427-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW Receipt No: Date of Payment: Septic Water Review ($62) : Both ($100) : Property Evaluation ($62+$45/Hr) : INSTRUCTIONS ' 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 the applicant an additional hourly rate of S40/hour as set forth by the Mason County Board of Health. PART 1: APPLIC /PARCEL IDENTIFICATION NAME OF APPLICANT r Y TELEPHO SITE/HOUSE ADDRESS C�rj 1 MAILING ADDRESS O ACREAGE (+� ASSESSOR'S PARCEL NOC'IBSR LEGAL PROPERTY DESCRIPTION \ n �L.R C;I l�' 1 suBDIVISION (If Applicable) - Div r BLR _ LOT DI CTIO FOR TING ITE VIA Ck — e- Sketch location of property in this'space. Z w H:\ON-SITEIF REVIEw.V R<vSa Son 03107196 1 : PART 2: PURPOSE OF APPLICATION 2A. OPTION ONE r--1 IJ I am applying for a bank loan and the bank has asked for an evaluation of the following: M LJ Septic System (Fee: S62) • Age of System • Age of House • Number of Bedrooms • Name of Last Amer • Is house currently occupied? -T— __W0_ • Attach punper'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: S62) • Number of service connections on water system If public water system: Ham of System r1 r LJ Both.(Fee: $100) • Provide information shown above for both septic and water systems 213. OPTION TWO LJ I am applying for a building permit, and environmental health has required an evaluation of the following: n LJ Existing Septic System (Fee: S62) • Age of System Number of Bedroom • Name of Last Owner • Is house currently occupied? es _70— • Attach pumper'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 originat 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: $62) - • Two property excavated pits are 4 ft deep must be ready for inspection by the department. M LJ Both (Fee: $62) • Provide information shown above for both septic system and reserve area Z OPTION THREE I am interested in knowing in general terms the suitability of a parcel for septic system placement. (Fee: $62 base, plus $45/hour after first hour) Describe the intended use of the property and the reason for requesting the review: R:%0N-SIT8ISRREVISw,w Revision 01/07/96 PART 3: PLOT PLAN Use this space to draw a detaited 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. C-) n Morn l - a1� con PART 4: AUTHO ATION --7 APPLIC DATE I N:\ON-SITE\SRRSVIEW.W Revision 01107196 PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY SA. DETERMINATION OF APPLICABLE STANDARDS The primary drainfield area must meet the following standards: n n U Meet current standards U Standard marine system n U No overt failure U Not applicable. The reserve drainfield area must 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 n U Meet marine expansion standards. U Not applicable. 513. WATER SYSTEM YES NO INDIVIDUAL WATER SYSTEM n n U LJ 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. LJU 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 U U The well site was inspected. No septic systems, chemical storage facilities, manure piles, animal feed lots, or other obvious sources of contamination were located within a 100 foot radius of the well. PUBLIC WATER SYSTEM n n U U Records indicate water sampling requirements are being satisfied. n n U LJ Records indicate the Water Facility Inventory form is current. uu Department files contain no information indicating the system is out of compliance with state or local water system requirements. 5C. SEPTIC SYSTEM YES NO Uu The septic tank was inspected by a certified septic tank pumper within the past 3 years and found to be In satisfactory condition. A pumper's evaluation is attached to this report. n n LJ LJ Records for this property contain a septic permit, design (if required), final inspection approval, and as-built approval. LJ LJLnJ The drainfield site was inspected, and appears consistent with recorded documents. n ULJ The drainfield area appears to be maintained in an acceptable manner. U LJ 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. rl n U LJ 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. a:\ON-SITE\EwREvrE .w Revision 01/07/96 r 9 I i y � Glut►.19/'1-}(iC-,��1�1'�J"AL!S`:�'Y'��J. . • AMWOR �iM1�s�lMA3�iZ�j1�i . Ifs%1l YlyiL��iTa'J1. C'7.L,/1if71,L�Ll77r�i'I1�.rJ�II:GTr11'll, �!La��V:%' �:'�IIti"IiJdIL4I,�iTi��(!4il/i1'Ll'JLJ♦IL:1J'Illvi'1lir��!�I L'L'�1/.'t:�/.!/ e1EAhilrlAV'll'/P:AR':'� P�ik"J'JU/Lhilllhl(//aL'%��:.1R!•7%LI:'%ll�l':+�1s-1Ii(i�l�»✓71J/��IJ17r/%SGi771„Y!!.'f�/°/� � ,•��!P/•//�i�i1��ilA1C � /��iriTi7 i� �I�i"n�\1nA►t.'Il"�1.LUG'/.�A1a7f:/�lO�iiTL111111►,' f��'1L/y1'ILI/JY►%//��L 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 has been made: u The system appeared to be functioning adequately at the time of inspection and and meets current design standards. n LJ The system appeared to be functioning adequately at the time of inspection. Not applicable. G6 •l�n �� 01 Tree Nil : /r Ifix 6B. RESERVE DRAINFIE EAt ) The reserve drainfield area wa inspected y sta and t e soil was evaluated. Site characteristics indicated an area exists that could support a septic system that would meet the following standards: n " Current standards. n u Marine expansion standards. —I u Marine repair standards, Treatment Standard Not applicable. s Comments: `r� �r 6C. WATER SYSTEM The water system was evaluated by staff the following determination has been made: n lJ 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. u 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 lend and critical area checklist may be required by Department of Community Development prior to issuance of developmental permit. INSPECTOR DATE i' H:\ON-SITE i EHREVIEW.W Revision 01/07/96