HomeMy WebLinkAboutSPH96-0004 - SPL Application - 1/10/1996 MASON COUNTY DEPARTMENT OF NEALTH SERVICES
POST OFFICE BOX 1666
SHELTON, WA 98584
(206) 427-9670
FAX 427-7798
APPLICATION FOR LAND USE EVALUATION
XC
Receipt No: C A Date of Payment: ' 7 �V
INSTRUCTIONS ---iii 3910
1. An application is considered complete When the fee is paid and the following etements hive been addressed:
• Parts 1 and'2 of the application form must be colleted.
• One property excavated backhoe pit per proposed parcel must be ready for inspection. Properly excavated pits
are 6 ft deep With a 4 ft deep shelf on one end of the pit. The 4 ft deep shelf must slope "p to the ground
surface for easy ingress and egress.
• A scaled plot plan must be attached,to the application. The scaled plot plan arust 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 coWleted application is received, staff will inspect the property and provide the applicant with a
written report,
IMPORTANT: IN ORDER TO AVOID ADDITIONAL COSTS, BE SURE TEST HOLES AND PARCELS ARE ALL FLAGGED AND CLEARLY I
DELINEATED AS TO LOT AND TEST HOLE NUMBER. THE IDENTIFIED TEST HOLES MUST MATCH THE LOCATIONS SHOWN ON THE
PROPOSED PLAT MAP. I
PART 1: APPLICANT/PARCEL IDENTIFICATION
❑ Large Lot Subdivision Short Plat Subdivision BLA (Office Review)
$100 + $10/parcel $85 $400 + $20/lot $10
L1 O
• NAME OF APPLICANT TELEPHONE (3tCG � `19�
• MAILING ADDRESS e-Ii` CC t'Sg
City ae ip
• ASSESSOR'S PARCEL NUMBER
• LEGAL PROPERTY DESCRIPTION N�.�`I`( 5 -�� `� -6-r 1O `.i T1 Ie
J �9/ 9039z- �0393 4jj- � ,7
• LOT SIZES (AC�2ESJOT2 SQ FT) ?jam 1 � ^' —L
• DIRECTIONS FOR LOCATING SITfi -L��/
in le, 11 UF R
PART 2: INTENDED USE OF PARCEL , 'k1 9 199�
I NDED USE OF PROPERTY (Check One) : / n
Single family residence Multi-family resale �L GTW 1gPP �ORP
Other, specify:
• WATER SOURCE FOR PARCELS (Check One) :
t1
dividual wells LJ Community well
II:\ON-SITE\LNDUSE.0 Revised 12/05/94
Land Uae Evaluation
PART 3: HEALTH DEPARTMENT REVIEW (OFFICIAL USE ONLY)
SOIL LOGS AND SITS CHARACTERISTICS
LOT a I LOT a I fora 3 I (or a
I Test Pit A , Test Pit A , Test Pit A I Test Pit A I
I Q1 0-0 fin i 0-VW5,9 ,�l�
I too I ca�r� , -� la,m���n���l faa � ��►�>� I
I n1 i � ''/ 10
>np I36--gl C1.24W
f �YC1 I a0e Scat
I a. rotSC I C eGr�vll d97�
r
Depth of root pen.: J f , Deh�of"'root pen.: I Depth of rodt pen.: , Depth of root pen.:
Depth of mottling: I Depth of mottling: / , Depth of mottling: I Depth of mottling:
Depth to rest. layer: , Depth to rest. Layer:3le-4 Depth to rest. layer` s ) Depth to rest. layer: 3� I
Soil type (USDA): , Soil type (USDA): I Soil type (USDA): I Soil type (USDA): / I
Test Pit B , Test Pit B , Test Pit B I Test Pit B
I I I I i
I I I I I
Depth of root pen.: I Depth of root pen.: I Depth of root pen.: I Depth of root pen.:
Depth of mottling: _ , Depth of mottling: I Depth of mottling: _ , Depth of mottling:
Depth to rest. layer: I Depth to rest. layer: _ I Depth to rest. layer: _ I Depth to rest. layer:
Soil type (USDA): I Soil type (USDA): I Soil type (USDA): _ I Solt type (USDA):
Curtain drain needed? , I curtain drain needed? I curtain drain needed? ,AL I Curtain drain needed?
Slope (x): I Slope (x): j slope (x): �. I slope (x):
Ak I
I Shoreline? (Y/N): Shorelines (Y/N)IIII
: Shoreline? (Y/N): / Shoreline? (Y/N): I
Minimum lot size: / , Mini mum lot size:A f ' I Minimum lot size:A / I JE Minimum lot size:A /. _.
A Minimum lot size applies to new subdivisions and is defined as the mini" allowable land area per residence or residen-
tial equivalent (450 gallons per day).
COMMENTS
rG 2 V I I rre es-
v
01"
W�PPP,
N:\ON-SITE\LNDUSE.W Revised 12105194
Land Use Eval na ti on
PART 4: REVIEW SUMMARY (COMMUNITY DEVELOPMENT USE)
MEETS 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.
r=7
d 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 regula 'ons until the following condition are met:
iti ) it prior to approval have been met by th applicant.
111 He [ Official 0 e
PART 5: REVIE R GNATURE
Heall k
Official Date
H:\ON-SITEiLNUUSE.W Revised 12105194
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