HomeMy WebLinkAboutCRT94-0049 - CRT Application - 3/4/1994 MASON. COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SHELTON, WA 98584
j'f FA(FAX 427- 798
427-7798
Ap
4/ [J
MAR MiATION FOR ENVIRONMENTAL HEALTH REVIEW
"EALTH SERVICES Receipt No:
Date of Payment:
Septic Review: ✓
Water Review:
Property Evaluation:
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 complating Part 1Mc), the necessary paperwork is attached, and
required soil evaluation holes have been excavated.
2. afte a completed application Ss received, staff will inspect the property and provide the applicant with a
r
written report.
1. If the project requires the excavation of more than 1 test holes, the department may charge the applicant an
hourly rate of i17/bour as set forth by the Mason County Hoard of Health.
PART 1: APPLICANT/PARCEL IDENTIFICATION
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NAME OF APPLICANT �i\ �Q a ��-'rg r'r- TELEPHONE U //r
C� l, �i � dl�fe 11A .
SITE/HOUSE ADDRESS f/��
MAILING ADDRESS / !� (d`7 4 X y a t ACREAGE r�
td A/
_ Qoo (mod
ASSESSOR'S PARCEL NUMBER T
LEGAL PROPERTY DESCRIPTION �+`� i /�" Sr DIV BLK LOT
SUBDIVISION (If Applicable)
DIRECTIONS FOR LOCATING SITE • �
Sketch location of Property in this space.
no. Si Revised 12/28/93
PART 2: PURPOSE OF APPLICATION
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2A. OPTION ONE
I am applying for a bank loan and the bank has asked for an evaluation of the
foVwing wing-
Septic system (Fee: $50) ,�
• Age of System
• Age of Bougie
• Number of Bedrooms •� .) {[� r
• Name of Last owner ��/`ryV/
le
• Is house currently occupied? I./,/ _
• Attach pumper's report, dated within last 2 years, stating whether the system was pumped, the size and
condition of the tank, and the condition of the baffled.
water system (Fee: $40)
• Number of service connections on water system
• If public water system:
U soth (Fee: $68) �. w..�.
• Provide information shown above for both septic and water $yetems
2B. OPTION TWO
I am applying for a building permit, and environmental health has required an
evaluation of the following:
ElExisting Sep system (Fee: $50)
• Age of Sys / '-
• Number of B a
• Name of ,.at Rorer
• Is house currently me ed?
• Attach pumper'& report ated wv in last 3 years, stating whether the system was pumped, the size and
condition of the , and the rnnd an of the baffles.
• If the crigl septic permit cannot be mated and system leas than S years old, apply for n�+ On-Sits
sewage Di al Permit.
• If thO,tiriginal septic permit Cannot be locat nd system more than 5 years old, submit signed ad-built
54;d*ing from certified designer or professional OR
eer.
Reserve Area for Future system Repair (Fee: $40)
• Two properly excavated pits are 4 ft deep must be ready for in ction by the department.
❑ Both (Fee: $50)
• Provide information shown above for both septic system and reserve axes
2C. OPTION THREE
I am interests in knowing in general terms the suitability of a parcel for septic
system placemen (Fee: $40 + $3 our)
Describe the intended use of ro and the reason for requesting the review:
1
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No. sl • Revised 12/28/93
PART ,3: PLOT PLAN
?'s.
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Use this space to draw a detailed plot plan, or attach one to this application. A detailed plot plan is a that
shows the precise location of the test holes, existing septic systems, dimensions of the property, and station of any
- wells, roads, ox-other buildings on the property.
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PART FOUR: AUTHORIZATION
DATE
APPLICANT
No. 51 Rew-Sed 12/28/93
PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY
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5A. DETERMINATION OF APPLICABLE STANDARDS
The primary drainfleld area must meet the following standards:
El El
Meet currant standards Standard marine system
El
y'C No overt failure Not applicable.
The reserve drainfleld area must have site characteristics that could support a septic system that would meet the
following standards:
El
Meet current standards. Meet marine repair standards.
Meet marine expansion standards. Ket applicable.
5B. WATER SYSTEM
NO INDIVIDUAL WATER SYSTEM
❑ A water sample was taken by health department staff and analyzed. Total conform bacteria were
determined to be absent. Laboratory results are attached to this report.
El11 The well cap was inspected. The sanitary seal appears satisfactory.
El11 The well casing was inspected. The casing projected above ground and ground was sloped away from the
casing.
El44 The site was'lnep"ict%�` No septic systems, chemical storage facilities, manors piles, animal feed
f ` lots. Or other obvious sources of contamination were located within a 100 tout radius of the well.
PUBLIC WATER SYSTEM
Records indica ampling requirements are bein satisfied.
ElEl Records indicate t r Facility Inventory current.
partnmat files contain no information indicating the system is out of compliance with state or local
Water system requirements.
5C. SEPTIC SYSTEM
�YfpyP-ISF NO
ElThe septic tank was inspected by a certified septic tank pumper within the past 2 years and found to be
in satisfactory condition. A pumper's evaluation is attached to this report.
❑ El Records for this property contain a septic permit, design (if required), final inspection approval, and
as-built approval.
11 El The drainfleld site was inspected, and appears consistent with recorded documents.
The drainfleld area appears to be maintained in an acceptable manner. .
The drainfleld area (the area where the drainfleld is assumed to be located based on office records
and/or observed site conditons) appears to be maintained in an acceptable manner.
El o �t cdJs- q�IlJ�Z��o
The drainfleld also the area where the drainfleld is aeaused to be located based on di
awdfae-observed site conditons) show no indication of overt failure at the time of inspection.
No. S1 Revised 12/20/93
5D. SOIL CONDITIONS
TEST HOLE #1 TEST HOLE #2 TEST HOLE #3
Depth of root pen. : pth of root pe1� Depth of root pen. : _
Depth to restr. layer Dep to restr//layer Depth to restr. layer _
Soil Type: Soil T e// Soil Type: _
Vertical Separation:' Vertica aration:' Vertical Separation:"
Curtain dY inable? ( N/NA) :
Slope (A) :
Shoreline? (Y/N) :
F
K;nimum lot size:m
Designer level:
Vertical separation //l /the depth or unsaturated, original, nndlstnrbed soil Types 2-6 that exists between
the bottom or the subeurrue absorption system and a restrictive layer or the tertable. Vertical separation for purposes or designating designer level will be calculated by the health 48p ent based on a 12-inch deep
5E. OTHER NOTES AND COM ENTS
a
Ro. S1 Revised 12/28/93
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:
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.
El Not 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:
ElCurrent standards.
ElMarine expansion standards.
Marine repair standards, Treatment Standard
.Not applicable.
Comments:
6C. WATER SYSTEM
The ater system was evaluated by staff. the following determination has been made:
The water- source consists of an individual well that appears to be a
s tisfactory source of potable water for a single family residence. The water
was sampled, and coliform bacteria were found to be absent.
The water source is a public water system that appears to be in substantial
compliance with applicable regulations.
Comments:
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Findings and determlmtiom oC this review reflect observed conditions as they m�late�on�tM�afuthure evaluation
aucceas or failure
performed. Absolutely no claim is made by this Office, either expressed or implied,
of the systems and sites evaluated.
F
rce land andcritical area eckli t be required by Department of Comity Development prior to issuance oopmental permit. /
DATE 4
INSPECTOR
Va. St 2e��isad 12/29/97
MASON COUNTY
DEPARTMENT of HEALTH SERVICES
Shelton,Washington 98584
(206)427-9670 9 Belfair:275-4467
ENVIRONMENTAL HEALTH PERSONAL HEALTH WATER QUALITY
P.O. BOX 1666 303 N. FOURTH P.O.BOX 1666
DATE: 23 MARCH 1994
TO: FRED L. CRABTREE
P.O. BOX 465
SHELTON, WA 98584
FROM: GUY GRAYSON
Environmental Health Specialist
SUBJECT: Water Sample and Well Disinfection
The result from the water sample taken on 03/07/94
was not satisfactory because coliforms were
determined to be present.
Your well will need to be disinfected before another sample
can be taken.
It will be necessary for you to disinfect your well .
Well disinfection is not difficult.
Enclosed are instructions for the procedures for doing this.
Please disinfect your well and then notify this office so that
another sample can be taken.
DIRECTIONS FOR DISINFECTING CONTAMINATED WELLS AND NEW WELLS
First, BE SURE your well is protected in the following manner
(otherwise its disinfection is useless and the well should be abandoned
until corrections are made) :
1) Tight cover excluding surface water and dirt.
2) Curb extending above surface of ground.
3) Tight casing down to water-bearing strata.
4) Safe distance from privy, cesspool, barnyard or contaminated
creek (in average soil conditions, about 100 feet) .
5) Earth sloped to drain away from well .
DISINFECTION PROCEDURE
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