The URL can be used to link to this page

Home My WebLink AboutCRT94-0184 - CRT Application - 6/28/1994 MASON COUNTY DjftTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTON, WA 98584 V (206) 427-9670 "Ap FAX 427-7798 �90PPLICATION FOR ENVIRONMENTAL HEALTH REVIEW G� L_/ Receipt No: Date of Payment: �--a Septic Review: Water Review: 1/ Property Evaluation: INSTRUCTIONS Y 1D I 1. An application is considered complete when the fee is paid, Parts 1-4 of the application form are completed. (assistance will he 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 in received, staff will inspect the property and provide the applicant with a written report. 3. If the project requires the excavation of more than 3 test holes, the department may charge the applicant an hourly rate of $37/hour as set forth by the Mason County Board of Health. PART 1: APPLICANT/PARCEL IDENTIFICATION NAME OF APPLICANT Jeff Geibel , WRE/Himlie, Inc TELEPHONE ( ) 426-2646 SITE/HOUSE ADDRESS E 150 Kitwilllps Dr, Shelton MAILING ADDRESS P.O. BOX 729 WA 98584 ACREAGE 5.05 n on cy st to „p 6 - 7 5 - 0 4 1 1 0 ASSESSOR'S PARCEL NUMBER _ 3 2 1 3 -- — LEGAL PROPERTY DESCRIPTION Tr 11 of Survey 2/49 SUBDIVISION (If Applicable) DIV _ BLK _ LOT DIRECTIONS FOR LOCATING SITE H3 Nortia 2nd left past Deer Creek Store on Deer Creek Loop (?) qtraiqht hack 1/2 mile + right on Kitwillips hand made sign, follow over bridge to yellov ho,,qp an right Just-om-e-r bridge, Sketch location of property in this space. No. si Revised 12/20/93 PART 2: PURPOSE OF APPLICATION ..........................:;::::...................... .................. .................................................................................................. ...... 2A. 'OPTION ONE P( i am applying for a bank loan and the bank has asked for an evaluation of the following: Septic System (Fee: $50) • Age of System • Age of House • Number of Bedrooms • Name of Last Owner • is house currently occupied? • 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 baffles. Water System (Fee: $40) • Number of service connections an water system r • If public watersystem: �th (Fee: $�68), . Provide information shown above for both septic and water systems 2B. OPTION TWO I am applying for a building permit, and environmental he h has required an evaluation of the following: Existing Sept system (Fee: $50) • Age or Sy ate - • Number of a t t 0 th e r e Y_ Bedrooms S t a f em 0 oum. building (Fee: e 1 W e d n If g g 5 0 p • Name of Last d Owner permit, a environmental nt a 1 h h has • Is house currently occupied? we. • Attach pumper-s report, dat within last 3 years, ting whether the system was pumped, the size and condition of the tank, a the condition of the baffles- • If the original Sept permit cannot be located and system l...�t .. old, apply for new on-Site Sewage Disposal p t. old, • If the origin septic permit cannot be located and system more than 5 years old, submit signed as-built drawing f certified designer or professional engineer. Reserve Area for Future System Repair (Fee: $40) 6 Two properly excavated pits are 4 ft deep must be ready for inspection by the department. Both (Fee: $50) . Provide information shown above for both septic system and reserve area 2C. OPTION THREE I am interested in owing in general terms the suitabili -of a parcel for septic system placement. (Fe - -$40 + $37/hour) Describe the intended use of the proper and the reason requesting the review: N.. Sl • Revised 12/28/93 PART 3: PLOT PLAN .................... .............................. ............................................................................................................................ Use this space to draw a detailed 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, reads, or other buildings on the property. 4S C PART FOUR: AUTHORIZATION .......................................... .............................. .............................................................. ........................................ APPLICAN'. DATE N Sl Revised 12/28/93 PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY . ................... ............................................... ....... ..................... ....... ....... ...... 5A. ' DETERMINATION OF APPLICABLE STANDARDS The primary drainfield area must meet the following standards: 11 Meet current standard. Standard marine system K. overt failure Not applicable. The reserve drainEi.ld area must heve site characteristics that could support a septic system that Would met the following standards: Meet current standards. Meet marine repair standard.. Meet marine expansion standards. �-t applicable. 513. WATER SYSTEM YES NO INDIVIDUAL WATER SYSTEM D11 A water sample was taken by health department staff and analyzed. Total coliform bacteria Were determined to be absent. Laboratory results a,e attached to this report. V�the well cap was inspected. The sanitary seal appears satisfactory. Ct�C t,� P�'Vhe well casing was inspected. The casing projected above ground and ground was sloped away from the casing. Y�, 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 too toot radius of the well. PUBLIC WATER SYSTEM Record. Indica sampling requir re being satisfied. Facility In a Water Records indl Inventory form ant. Department t I . cc tei information indicating the system is out of c state or local rtment files contain no information indicating the system is out of compliance with water system requirements. 5C. SEPTIC SYSTEM YES NO The 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. �\,,C.rda for this property contain a septic permit, design (if required), final inspection approval, and as-built approval. * ke�5- El �ho drainfield site was inspected, and appears consistent with recorded documents. & [I The drainfield area appears to be maintained in an acceptable manner. vs- [] Y� The drainfield are. (the area where the drainfield is assumed to be located based an office records and/or observed site conditons) appears to be maintained in an acceptable manner. The drainfield area (the area where the drainfield in assumed to be located based an office records and/or observed site conditons) show no indication of evert failure at the time of inspection. No. SI . Remised 12/28/93 5D.' SOIL CONDITIONS TEST HOLE #1 TEST HOLE #2 TEST HOLE #3 I i Depth of root pen. : Depth of of pen. : Depth of root pen. : _ Depth to restr. layer Dept o restr. layer Depth to restr. layer Soil Type: it Type: Soil Type: Vertical Separation:" Ver ical Separation:" Vertical Separation:' curtain drain ble? (Y/N/NA) : Slope (�) : Shoreline? (YIN) : Minimum lot size:" Designer level: vertical separation is the depth of unsaturated, original, and turbad soil of lypee 2-6 that exists between the bottom of the subsurface absorption system and a restrictive yer or the watertable. Vertical separation for purposes of designating designer level will be calculated by health department based on a 12-inch deep 5E. OTHER NOTES AND COMMENTS t any nnK 1 i No. S1 Revised 12/28/93 PART 6: HEALTH DEPARTMENT DETERMINATION - OFFICIAL USE ONLY ...................I.............................. ....................................... .................................................................................... GA. 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. KThe system appeared to be functioning adequately at the time of inspection. E] 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: Current standards. Marine expansion standards. Marine repair standards, Treatment Standard Pi-not applicable. Comments: 6C. WATER SYSTEM The water system was evaluated by staff the following determination has been made: XThe 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. E3The water source is a public water system that appears to be in substantial. compliance with applicable regulations. Comments: ............................................................................................................................................. ................................ Findings and determinations of thin 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 land and critical area checklist may be required by Department of Community Development prior developmental permit. L( INSPECTOR DATE Revised 12/28/93