HomeMy WebLinkAboutSPH93-0189 SPL2390 - SPL Application - 12/3/1993 MASON COUNTY DEPARTMENT OF HEALTH SERVICES
oo POST OFFICE BOX 1666
SHELTON, WA 98584
(206) 427-9670
FAX 427-8425
APPLICATION FOR SHORT PLAT EVALUATION
Receipt No:
INSTRUCTIONS _01 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 moat be ready for inspection. Properly excavated Pita
are 6 ft deep with a 4 ft deep shelf on one end of the pit. The 4 ft deep shelf must slope up to the ground
surface for easy ingress and egress.
• A scaled plot plan most 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 ft 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 teat holes and completion
of this report, an hourly rate of $37/hour as set forth by the Mason county Board of Health may be charged to
Revised 09/01/92
the applicant.
PART 1: APPLICANT/PARCEL IDINTIFICATION
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• NAME OF APPLICANT CICA-V-OAVl '�" 1.c� y.an n'e �Fi��"'e • TELEPHONE'' (LL ) �•I.1
1 HO)tykG.r .E0S50C...
• MAILING ADDRESS I�A� �� �� ��Cxd
69 nou) �baDo
CYty BCst Slp
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• ASSESSOR'S PARCEL NUMBER
• LEGAL PROPERTY DESCRIPTION S L.J �1 uI SL ��`I '3 k."c
• LOT SIZES ACRE OR SQ FT) Sa �•�� `� . S -) . bry
,II Lot 1 LOG 2 I L L
e< 3 ob
• DIRECTIONS FOR LOCATING SITE A( e if A.
PART 2: INTENDED USE OF PARCEL
• INT NDED USE OF PROPERTY (Check One) : El .
Single family residence Multi-family residence
other, specify:
• WATER SOURCE FOR PARCELS (Check One) :
Individual wells Community well
--
.. short Plat Evaluation
PART 3: HEALTH DEPARTMENT REVIEW (OFFICIAL USE ONLY)
SOIL LOGS AND SITE CHARACTERISTICS
LOT 1 ' LOT f LOT M LOT I
Test Pit A Test Pit A Teat Pit A Test Pit A
P c-v 0-7 ti
7N p o�Qo�9 �1
5� ( o _
Sol Sw5 �"� 8
Ad
3 s nAj urt9 er "r 40
Depth of mot pan.: N Depth of root pen.: 3�
Depth of mot pen.: UJ Dept roc
ro .:
,7 u
Depth of mottling: Depth of mottling: I Depth of mottling:_ Depth of mottling: �_
n
Depth to rear. layer: 41"- Depth to rest. layer: , „ Depth to rest. layer: 3 Depth to rest. layer:
Soil type (USDA): 3L Soil type (USDA): 3 Soil type (USDA): 3 Soil type (USDA): _`�
Test Pit B Test Pit B Test Pit B Test Pit B
Depth of mot pen.: Depth of root pen.: Depth of root 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. layer:
Soil type (USDA): t / soil type (USDA): Soil type (USDA): Soil type (USDA): _n,_
Curtain drain needed? /� Curtain drain needed? h /:�� Curtain drain needed? Curtain drain needed? 1 `�
Slope (S): Z18% Slope (%): L�`-' /V slope (%): L,' t slope (t):
��
Shoreline? (YIN): Shoreline? (YIN): Shoreline? (YIN): ' shoreline? (YIN):
Minimum lot size:' Minimum lot size:- I Minimum lot size:a ^^"r Minimum lot size:- J,
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).
COMMENTS
wrA)\n rn/n g In�`3
Short Plat Evaluation
PART 4: HEALTH DEPARTMENT REVIEW SUMMARY (COMMUNITY DEVELOPMENT USE)
XMMTS HEALTH CODE
After examining lot size, proposed water source, and soil type, it is the de-
termination of Mason County Department of Health Services that each proposed
parcel can support an on-site sewage disposal system meeting the requirements
of state and local regulations.
® DOES NOT MEET HEALTH CODE
After examining lot size, proposed water source, and soil type, it is 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.
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 is 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:
ElCondition(s) required prior to approval have been met by the applicant.
Health Official Date
PART 5: REVIEWER SIGNATURE
Health Official Date