The URL can be used to link to this page

Home My WebLink AboutCRT99-0108 - CRT Application - 7/12/1999 MASON COUNTY DEPARTMENT SERVICES POST OFFICE BOX 1666 SHELTON, WA 98584 (360) 427-9670 FAX 42 7-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW Receipt No: Date of Payment: — Septic 4L �gpr Review ($85) : _ Both ($100) : Property Evaluation ($85+$50/Hr) : INSTRUCTIONS 1. An application is considered complete vhen the,fee is paid, Parts 1-4 of the application form are completed. (assistance will be provided upon request for completing Part Teo), the necessary papereork 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 pork, the department will charge the applicant an additional hourly rate of f50/hour as set forth by the Mason County Board of Health. PART 1: APPLICANT/PARCEL IDENTIFICATION NAME OF APPLICANT in SQ�_'R J S� C ►4 c e TELEPHONE (9Go) SITE/HOUSE ADDRESS I '2O `1 o pi erne IC 2 d 1.= MAILING ADDRESS ":;)b �K Cj SL �orJ y a1� ACREAGE cit �ip ASSESSOR'S PARCEL NUMBER - Q- LEGAL PROPERTY DESCRIPTIONrr k Ajar SUBDIVISION (If Applicable) DIV _ BLK — LOT DIRECTIONS FOR LOCATING SITE Sketch 1 ation of property in this space. r erQeIL 3� H:\ON-SITE\EHREVIEW.N Revision 12/17/97 PART 2: PURPOSE OF APPLICATION 2A_ OPTION ONE XI am applying for a bank loan and the bank has asked for an evaluation of the following: n u Septic System (Fee: $85) . Age of System • Age of House Number of Bedrooms Name of Last Owner Is house currently occupied? _Te—s— _-Fo— Attach purper's report. dated within.rlast 3 years. stating whether the system was pumped. the size and condition of the tank. and the condition of the baffles. KNater System (Fee: $85) Number of service connections on water, system ('`JQ If public water system: ame OT Sys�— n WFI Number u Both (Fee: $100) Provide information shown above for both septic and water systems 2B- OPTION TWO El I am applying for a building permit and environmental health has required an evaluation of the following: n u Existing Septic System (Fee: $85) • Age of System Number of Bedrooms • Name of Last Owner Is house currently occupied? - Attach punper's report, dated within last 3 years. stating whether the system was puped. 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 original septic permit cannot be located and system more than 5 years old. submit signed as-built drawing from certified designer or professional engineer. n u Reserve Area for Future System Repair (Fee: $85) Two properly excavated pits are 4 ft deep must be ready for inspection by the department. n u Both (Fee: $85) Provide information shown above for both septic system and reserve area H:\ON-SITE\EHREVIEW.W Revision 12/17/97 2C- OPTION THREE El I am interested in knowing in general terms the suitability of a parcel for septic system placement. (Fee: $85 base, plus S50/hour after first hour) Describe the intended use of the property and the reason for requesting the review: 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. roads. or other buildings on the property. 1, PART 4: AUTHORIZATION APPLICANT �/ �/NJ�S2+ - R DATE HAON-SITBEHREVIEW.N Revision 12/17/97 PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY 5A. DETERMINATION OF APPLICABLE STANDARDS The primary drainfield area must meet the following standards: n n u Meet current standards u Standard marine system n 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 th following standards: n n u Meet current standards. u Meet marine repair standards. n n u Meet marine expansion standards. u Not applicable. 5B. WATER SYSTEM YES NO INDIVIDUAL WATER SYSTEM n u 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. n u The well cap was inspected. The sanitary seal appears satisfactory. n �1 u The well casing was inspected. The casing projected above ground and ground was sloped away from the casing. n 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. -WIc- �eccrol NiF local . PUBLIC WATER SYSTEM n n u u Records indicate water sampling requirements are being satisfied. n n u u Records indicate the Water Facility Inventory form is current. n n u u Department files contain no information indicating the system is out of compliance with state or local water system requirements. 5C. SEPTIC SYSTEM YES NO n n u u The septic nk was inspected by a certified septic pumper within the past 3 years and found to be in satisfacto condition. A pumper's evaluati is attached to this report. n r1 u u Records for this pro rty contain a se c permit, design (if required). final inspection approval. an( as-built approval. n n u u The drainfield site was ins d. and appears consistent with recorded documents. n rr u u The drainfield area appears to be ma tained in an acceptable manner. n n u u The drainfi d area (the area where the dra field is assumed to be located based on office records and/or erved site conditons) appears to be 'ntained in an acceptable manner. n n u u e drainfield area (the area where the drainfield is ssumed to be located based on office records and/or observed site conditons) show no indication of overt failure at the time of inspection. H:\ON-SITE\EHREVIEW.W Revision 12/17/97 50. SOIL CONDITIONS TEST HOLE #1 TEST HOLE #2 TEST HOLE #3 Dept4i to restr. layer De h to restr. layer Depth to restr. layer Soil Type: Soil pe: / — Soil Type; _ FINDING SCORE Soil Type: Soil Depth: Slope: Parcel Size Distance o Shoreline: / 5E. OTHER NOTES AND CENTS 1 HAON-SITBEHREVIEW.N Revision 12/17/97 PART 6: HEALTH DEPARTMENT DETERMINATION - OFFICIAL USE ONLY 6A. PRIMARY DRAINFIELD SYSTEM The primary dNinfield area was inspected by staff and pertinent records were reviewed. The following determination was made: ❑ The system app red to be functioning adequately at the time of inspection and and meets Curren design standards. El The system appeared be functioning adequately at the time of inspection. ❑ Not applicable. % Comments: 6B. RESERVE DRAINFIELD AREA The reserve drainfield are as in5.pect by staff and the soil was evaluated. Site characteristics ind' ated an area a 'sts that could support a septic system that would meet the fo owing standards: Current stan rds. El Fie ansion standards. air standards. Treatment Standard El able. Comments: 6C. WATER SYSTEM The water system was evaluated by staff 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 found to be absent. El The water source is a public water system that appears to be in substantial compliance with applicable regulations. Comments: .... ........... ...........•..••••.••••••••••..••••.••.••.•:...................:i�>,'iwircii'w'Y:vxHwlH'iiiN:Nriv::.:'N,wiirci:v".ririv'riv>w):iiwiwlw'i'x"i"Nii,»li))i!wii>i)"N'J„ .3)'R,),.iii•• �F,.W.`W%vu,,,,.w.v:mm,x.w.w..,.wnr.w,:..w,,,nw,i,,.iv,H "i:liHriww):4))i'HI,i:w"m••HY •••••..••••.•••••• 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 land and critical area checklist may be required by Department of community Development prior to issuance of developmental permit. INSPECTOR — DATE ��lr n H:\0N•SITE\EHREVIEII.R Revision 12/17/97