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Home My WebLink AboutCRT2002-00131 - CRT Application - 9/3/2002 MASON COUNTY RECEIVE D DEPARTMENT OF HEALTH SERVICES SY 0320002UU, 426 W CEDAR ST, PO BOX 1dA// A 9sE�TRW 8584 SHELTON (360)427 9670 ELMA (360)482-5269 BELFAIR (360 275-4467 SEATTLE (206)464-6968 WEB hW://www.co.niason.wa.us FAX (360)427-7798 APPLICATION FOR ENVIROMENTAL HEALTH REVIEW PERMIT NUMBER PAYMENT INFORMATION TYPE OF VIE (} Septic and Wat $150 CRT Receipt Number l "f Septic $100 ❑ Cash FEI Water $100 l�(�I,'� �] Check IT O Property Evaluation $100+$50.hr. Resample$50 hr+lab fee Date of Payment *After 1"hour 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 IDENTIFICATION 7 �7 V Name of Applicant 1�4 -Oq(le Abf`1 (Ul a-i(? Telephone -ju of j /2 Mailing Address ofApplicant �oa�n/s City I � Fit ( (� State `' V A Zip q �j D 12 Digit Tax Parcel No. Z 3 G j(� _ / -�J3 _cjJ C� nO S �, Site Address �� N� C f Id w�C� ly ed .. -'e I r \NA C� 5D� Brief Legal Descriptioq . Driving Directions rlmm Bel1' old Pei ✓ OL%v to rx - C Tl- Go -4 -- S ►g i LQA U2 VV t . ?age 1 of 4 PART 2: TYPE OF REVIEW Septic System • Age of System ■ Age of House,• S ■ Number of Bedrooms r C � ■ Name of Last Owner n bn 1«na 1P • Is House Currently Occupies ®YES ONO If not Occupied, how long has it been vacant? Water System ■ Number of Service Connections on the Water System oY)P— • If a Public Water System,Name of System ■ WFI Number ❑Property Evaluation (soil logs) ■ Property evaluations provide,in general terms, the suitability of a parcel for septic system placement. THIS DOES NOT GUARANTEE FUTURE SEPTIC SYSTEM APPROVAL ■ Describe the intended use of the property and the reason for requesting the review PART 3: PLOT PLAN Use the space-below to draw a detailed plot plan, or attach a detail plot plan to this application. The plot plan should include the following: North Arrow,Precise Location of Test Holes,Location of Existing Septic System, Dimensions of Property, Location of any Drinking Water Sources (wells,springs, etc...), Roads,Easements, Surface Water,and Buildings on the Property. LOT SIZE Lk we �� c 1 c C (1 1 + Acres v Applicants Signature: �— Date: 3—CI--y Page 2 of 4 pART 4: HEALTH DEPARTMENT FINDINGS—OFFICIAL USE ONLY Septic System Yes No ❑ The septic tank was inspected by a certified septic tank pumper within the last 3 years and was found to be in satisfactory condition. A pumpers report is attached. Records for this property contain a septic permit, design, final inspection approval and an as-built draw in . The site was inspected and the system location appears to be consistent with recorded documents. The area of the on-sites stem appears to be maintained in an acceptable manner. Was Operation and Maintenance a condition of permitapproval? Is a copy of current Operation and Maintenance report attached? Water System Individual Water System Yes No )}`�7" ❑ 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. The well cap was inspected. The sanitary seal appears satisfactory The well casing was inspected. The casing projected above ground and the ground was sloped away from the casing LJ The well site was inspected.No septic systems,chemical storage facilities, manure piles, animal feedlots or other obvious sources of contamination appeared within 100-foot radius of the well. Public Water System Yes No ❑ ❑ Records indicate wat am lin uirements are being satisfied. Records indicate the WattFacihty Inventory form is current. —[]--[]—Department files contain water stem designand letter of approval Soil Conditions Test Hole#1 Test Hole#2 Tss!-Ilole#3 i� Soil Type: Soil Type: Soil Type: Restr. Layer: Restr. Layer: Restr. Layer: Slope: Slope: Slope: Distance to Shoreline Distance to Shoreline Distance to Shoreline Page 3 of 4 PART 5f HEALTH DEPARTMENT OBSERVATIONS—FOR OFFICIAL USE ONLY Primary Drain field Staff inspected the primary'drain field area and when available, pertinent records were reviewed. The following determination was made Yes No ❑ The system appears to be functioning adequately at the time of the inspection. (only applicable if system has been in use on a re lar basis for the last 6 months El Sanitary survey? Pass Fail Lj Suspect Lj Not applicable Water System Staff evaluated the water system and the following determination was made No ❑ The water source consists of an individual well the appears to be a satisfactory source of potable water for a single-family residence. The water was sampled and coliform bacteria were absent. The water source is a public water system that appears to be in compliance with the applicable regulations Well Construction Permit Pass LJ Fail PART 6: CONBIENTS IV-sl- sa c, aSEM A dos�ckt, 4,y� 4s6jM axAc\ Lna4 6L lorAdcd ow fecoJdt 40 iw1;G4)jk hn� .} q-.0 Sk&- s.� wwTs Q�r� h+e rle5�a e Av_�p-fowe . ire. wV64 nro 'ZU dC '-\a 6F "1- +} g Jl fty A INSPECTOR 6 1��— /{�4c ; ,�o, �,�, DATE 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. Page 4 of 4 Mason County Environmental Health Department Septic Tank Pumpivn�g Re ort Form ?� �'1 fX ✓�w� Property owner/Mailing Address�,L' � a_ l(�� 0 DD 0� Site Address_ o4k1 ) N6 ,�/��0-rL � Tax Parcel NumberO�O 1 � G)OfieC,a4 Description , �e h5 �'''^ $^ lR'fl..Y l4<>`".<'F S+` L•F;" 't%?$.: :x �tQ: %�'a.ro<`Cv`Sa�$ia.W.i due. .w s,�., „_..�'%<n�^. ' .¢a:," 2.4a.✓ r^'a.,<:..c :^'az.....,,.F..Aa,,..tiFr."�'. . '�'. .«.,u uaxae�na. ,�........,.a'r.;.<°fa':.�,5°a»'c��.,,,.r.•<.G.`Er. .... �` •.` (Punper's Finding's) All items must be filled out completely, circle answer as needed. Septic Tank Information 1) Tank pumped and inspected: ye or no Effluent level: high / n rma / mow 2) Tank size: IZoo gallons 3) Tank construction: manufacture or home made Tank material: metal wood oncrete fiberglass other 4) How many compartments? single or(doub 5) Inlet Baffle condition: atisfactory needs repair Outlet Baffle condition: PP/ F/� i £ needs repair Center Baffle condition: o needs repair / not applicable Effluent filter cleaned: not applicable 6) Does the system have a pump chamber? es / no / unknown Did the pump chamber need to be pumped? / no / not applicable 7) Tank condition: damaged / good Were the tank or the baffles repaired? yes / no / not applicable Solids level (optional) : Sludge / Scum Drainfield condition: backflow the tank / seepage in drainfield / no obseryed problems 8) location where septage was disposed & (n 9) Abnormal observations: (if repairs were made, please explain) Findings and determinations of this inspection reflect conditions as they existed on the day the septic tank was pumped. No claim is made by this company, either expressed or implied, concerning success or failure of the septic system. P MM 9 _3 _ ;g,(7Oa- Signature of certified pumper U_�L�J Datejw " Name of Compan S'� (( (.C.('ti Il Mason County Department of Health Services 410 North 4th•Shelton,WA 98584 427-9670 ext.580 _ WATER BACTERIOLOGICAL ANALYSIS SAMPLE COLLECTION; READ INSTRUCTIONS THOROUGHLY DATE COLLECTED TIME COLLECTED COUNTY NAME t' MONTH �DAV /YEAR �:L1 TYPE OF SYSTEM�/��1'.'IIFF PUBLIC SYSTEM,COMPLETE: ❑PUBLIC INDIVIDUAL I.D.NO. CIRCLE GROUP A B (serves only 1 residence) NAME OF SYSTEM E 5480 l.1>` umc k 5 SPECIFIC LOCATION WHERE SAMPLE COLLECTED TELEPHONE NO. �` - 3, ou}d&v MP DA2_YW1 110 — 2neup_ b qfi� V �► EVENING( ) SAMPLE COLLECTED BY:(Name) SYSTEM OWNER/MGR:(Name) Iq Igv�wl g' SOURCE TYPE GROUND WATER UNDER SURFACE INFLUENCE ❑SURFACE WELL or ❑SPRING ❑PURCHASED or ❑COMBINATION ELL FIELD INTERTIE or OTHER 8 ? SEND REPORT TO:(Print full Name,Address and Zip € F I WASHINGTON TYPE OF SAMPLE , (check only one in this column) x ❑ Chlorinated(Residual:—TotalFree) ' IOUTINE ❑ iltered DRINKING WATER 31 Untreated or Other check treatment G ❑ REPEAT SAMPLE Lab# Previous coliform presence Date } ❑ RAW SOURCE WATER Source# R m ❑Total Coliform ❑ NEW CONSTRUCTION or REPAIRS ❑Fecal Coliform ?e ❑OTHER(Specify) REMARKS: (LAB USE ONLY)DRINKING WATER REST) ❑UNSATISFACTORY,colilorms present SATISFACTORY REPEAT ❑E.Coli present ❑E.Coli absent Coliforms absent SAMPLES REQUIRED ❑Fecal present ❑Fecal absent OTHER LABORATORY RESULTS TOTAL COLIFORM_/100 ml E.COLT_/100 ml FECAL COLIFORM_/100 ml PLATE COUNT MIT ANOTHER SAMPLE REQUIRED : SAMPLE NOT TESTED BECAUSE: TEST UNSUITABLE BECAUSE: ❑Sample too old ❑Confluent growth i ❑Wrong container ❑TNTC ?f ❑Incomplete form ❑Turbid culture ❑ O Excess debris - SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS LAB NO.(7 DIGITS) DAT�• +T ME RECEIVED 1 oss p� ,I,.J�.t f._ y 9 00 la,Is P� DAqRFPARTED LABORATORY: WHITE-DP Center Copy BLUE-Laboratory Copy GREEN-Water Supplier Copy