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Home My WebLink AboutCRT2002-00068 - CRT Application - 5/13/2002 MASON COUNTY MAY 18 2U0� DEPARTMENT OF HEALTH SERVICES HEALTH c-;FRV'Q' F&k1h&. 426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584 SHELTON (360)427-9670 ELMA (360)482-5269 BELFAIR (360 275-4467 SEATTLE (206)464-6968 WEB hqp://www.co.mason.wa.us FAX (360)427-7798 APPLICATION FOR ENVIROMENTAL HEALTH REVIEW PERMTI NUMBER PAYMENT INFORMATION TYPE OF REVIEW p �ry Septic and Water $150 CRT Receipt Number O ` ❑ Septic or Water $100 13 v z ❑ Property Evaluation $100+ $50 hr (� Date of Payment ( I ❑ Resample $50 hr+lab fee Important Notice: Findings&determinations of this review reflect observed conditions as they existed on the day the evaluation was preformed. Absolutely no claim is made by this office, expressed or implied concerning the future success, failure or permit approval of the system and site evaluated. *** FILL OUT APPLICATION COMPLETELY AND ACCURATELY *** An application is considered complete when the fee is paid,parts 1, 2 and 3 of this application form are completed, necessary paperwork is attached(i.e. pumpers report) and when required, soil evaluation holes have been excavated. PART 1: APPLICANT/PARCEL IDENTIFFICATION Name of Applicant Telephone Mailing Address ofApplicant C - y`B KiKh1F I- �7uj(� City 'C_)xH1 () State 'U0A Zip � dam' l 12 Digit Tax Parcel No. j - - Brief Legal Description 1 R t 1 ' � e ti� l n�,- I �Il l a 1 [i iac { u u ( (v W'Lbr tis ` Lt"'c C;kl e. x��.c b1-tt Y ��,urt�w�.s� Driving&iredions L)a��e C'>acckc{ �� Iz cn l�l�� %� r.r\ MFSC�1LAke L ornk r6flea 2iV v4i f" SKETCH LOCATION OF PROPERTY IN THIS SPACE rUx 40 PC F-C-LP, 4Y f c v 02- 4y3K 2a. Certification for Financial Institute or Property Transaction Septic System (Fee$100) • Age of System • Age of House • Number of Bedrooms • Name of Last Owner • Is house currently occupied? Yes/No(circle one) • Has house been occupied on a regular basis for the last 30 days? Yes/No(circle one) Water System(Fee$100) • Number of service connections on the water system 3 • If a public water system,name of system • WFI Number 0:2 4 R Both(Fee$150)-Fill out the above for septic and water 2b. Property Evaluation(soil logs) I am interested in knowing in general terms the suitability of a parcel for septic system placement.(Fee$100 base,plus $50/hr. after first hour). Describe the intended use of the property and the reason for requesting the review: PART 3: PLOT PLAN Use the space to draw a detailed plot plan, or attach one to this application. The plan should include the following: North arrow, precise location of test holes,location of existing septic system,dimension of the property, location of any drinking water sources(wells, springs etc.),roads,casements, surface water, and other buildings on the property. tJel r vO6 /I � �oC Lot Size: S P ` ]3ac 1/ t C (� I I � Applicant's Signature: Date: S��l�• Z PART 4: HEALTH DEPARTMENT FINDINGS—OFFICIAL USE ONLY 4a Water System Yes No Individual Water System 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. 0 0 The well cap was inspected. The sanitary seal appears satisfactory. 0 The well casing was inspected. The casing projected above ground and ground was sloped away from the casing. QThe well site was inspected. No septic systems, chemical storage facilities,manure piles,animal feed lots,or other obvious sources of contamination were located within 100 foot radius of the well. Yes No Public Water System nRecords indicate water-sampling requirements are being satisfied. 0 Records indicate the Water Facility Inventory form is current Department files contain water system design and letter of approval 4b. Septic System Yes No p( 0 The septic tank was inspected by a certified septic tank pumper within the last 3 years and found to be in satisfactory condition. A pumper's report is attached. �dl Records for this property contain a septic permit, design, final inspection approval,and as-built drawing. ® Q The site was inspected and the system location appears to be consistent with recorded documents. VThe area of the on-site system appears to be maintained in an acceptable manner. 0 Was Operation&Maintenance a condition of permit approval? �. Is a copy of a current Operation&Maintenance report attached? 4c. Soil Conditions Test Hole#1 Test Hole#2 Test Hole#3 Soil Type: Soil Type: Soil Type: Restr. Layer: Restr. Layer Restr. Layer_ Slope:_ Slope:_ Slope:_ Distance to Shoreline: Distance to Shoreline: Distance to Shoreline: Other Notes and Comments PART 5: HEALTH DEPARTMENT DETERMINATION—FOR OFFICIAL USE ONLY Sa. Primary Drainfield Staff inspected the primary drainfield area and when available pertinent records were reviewed. The following determination was made: The system appears to be functioning adequately at the time of inspection(only applicable if system has been in use on a regular basis for the last 6 months). The system meets current design standards. A sanitary survey was performed on this property. Not Applicable Comments: 5b. Water System Staff evaluated the water system and the following determination was made: 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 to be absent. aThe water source is a public water system that appears to be in compliance with applicable regulations. 1ya e aWell construction Comments: cn .r4w. Cam. Xt a �n Uj F T .o v✓ ,JLcn �.F1'c+-� ,OL,' a t ct INSPECTOR C W(Jk DATE I J g j oZ Findings and determination ofthis review reflect observed conditions as they existed on the day the evaluation was performed. Absolutely no claim is made by this office, expressed or implied,concerning the future success,failure, or permit approval of the systems and sites evaluated.