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Home My WebLink AboutCRT96-0162 - CRT Application - 9/5/1996 MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTON WA 98584 (31?0) 427-9670 FAX 42 7-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW Receipt No: 1 Date of Payment: Sep is r Water Review ($62) : XX Both ($100) : rty Evaluation ($62+$45/Hr) : INSTRUCTIONS ' 1. An application is considered complete When the fee is paid, Parts 1-4 of the application form are completed. (assistance Will be 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 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 work, the department will charge the applicant an additional hourly rate of $40/hour as set forth by the Mason County Board of Health. PART 1: APPLICANT/PA�9RCE�Ly�IDENTIFICATION 4y/I —7 NAME OF APPLICANT 1C !J �YY� 1]"�� TELEPHONE (SL'fJ SITE/HOUSE ADDRESS ) /L� ` I��„�LL LeZ SL—/tJ MAILING ADDRESS CTT a Lip ACREAGE ASSESSOR'S PARCEL NUMBER 2 L LEGAL PROPERTY DESCRIPTION LOB : � .T. SUBDIVISION (If Applicable) DIV — BLK LOT V_ I CTIONS FOR TING S a IT£ 1 / K c�,� �� ALA A srD Sketch location of property in this space. I i H:ION-SITEIEHREVIEW.W Revision 01/07/96 PART 2: PURPOSE OF APPLICATION 2A. OPTION ONE F1 LJ I lying for a bank loan and the bank has asked for an evaluation of the foll ing: mJ Sept ie System (Fee: $62) • Age of System • Age of House • Number of Bedrooms Name of Last Owner 0 Is house currently occupied? -Yes • Attach pumper's report, dated within last 3 years, stating whether the system was purped, the size and condition of the tank, and the condition of the baffles. n LJ Water System (Fee: $62) • Number of service connections on water system • If public water system: Nam or system n WFL LJ Both (Fee: $100) Number Provide information shown above for both septic and water systems 213. OPTION TWO n LJ I am applying for a building permit, and environmental health has required an evaluation of the following: n LJ Existing Septic System (Fee: S62) Age of System • Number of Bedrooms Name of Last Owner • Is house currently occupied? des —Ro • Attach pmaper's report, dated within last 3 years, stating whether the system was pupped, 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 LJ Reserve Area for Future System Repair (Fee: $62) _ • Two properly excavated pits are 4 ft deep must be ready for inspection by the department. n LJ Both (Fee: $62) • Provide information shown above for both septic system and reserve area 2C. OPTION THREE n LJ I am interested in knowing in general terms the suitability of a parcel for septic system placement. (Fee: $62 base, plus $45/hour after first hour) Describe the intended use of the property and the reason for requesting the review: N:10N-SITE�EHREVZEN.N Revision 01/07/96 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. PART 4: AUTHO ATION APPLICANP � DATE H:WN-SITE%EHRE IEW.w Revision 01107196 PARS' S: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY SA. DETERMINATION OF APPLICABLE STANDARDS The prim drainfield area must meet the following standards: r n /.o current standards LJ Standard marine system vert failure u Not applicable. The reserve drainfield area must have site characteristics that could support a septic system that would meet the following ndards: n 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 n u 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 n U LJ The well cap was inspected. The sanitary seal appears satisfactory. n n U U The well casing was inspected. The casing projected above ground and ground was sloped away from the casing. n n u 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. PUBLIC WATER SYSTEM n n I__I LJ Records indicate water sampling requirements are being satisfied. n n u LJ 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 u L2VThe septic tank was inspected by a certified septic tank punper within the past 3 years and found to be in satisfactory condition. A pumper's evaluation is attached to this report. n Records for this property contain a septic permit, design (if required), final inspection approval, and as-built approval. �y The drainfie Ld site was inspected, and appears consistent with recorded documents. }� The drainfield area appears to be maintained in an acceptable manner. n u u drainfield area (the area where the drainfield is assumed to be located based on office records and/or observed site conditons) appears to be maintained in an acceptable manner. F-1 u The drainfield area (the area where the drainfield is assumed to be located based on office records and/or observed site conditons) show no indication of overt failure at the time of inspection. H:ION-SZTE\EHREVIEW.W Revision O1107196 5D. SOIL CONDITIONS EST HOLE #1 I TEST HOLE #2 I TEST HOLE #3 Depth of root pen. : \Depth root pen. : � Depth of root pen. : Depth to restr. layer restr. ayer Depth to restr. layer Soil Type: e: Soil Type: Vertical Separation:AS paration:A Vertical Separation:A Curtain dra' able (Y/N/NA) : Slope (�) Shorel' e? (YIN) : Min' um lot size:$ D signer level: Vertical separation is/he depth of unsaturated, original, undistur soil of Types 2-6 that exists between the bottom of the sul3obrface absorption system and a restrictive layer r the waterteble. Vertical separation for purposes of desAnatim designer level will be calculated by the hea th department based on a 12-inch deep SE. OTHER NOTES COMUENTS R:10W-SITEIEHRWTEW.W Revision 01/07/96 PART 6: HEALTH DEPARTMENT DETERMINATION - OFFICIAL USE ONLY 6A. PRIMARY DRAINFIELD SYSTEM The primary drainfield area was inspected by staff and pertinent records were reviewed. The following determination has been made: n The system appeared to be functioning adequately at the time of inspection and and meets current design standards. The system appeared to be functioning adequately at the time of inspection. I—I u 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. n LJ Marine expansion standards. r1 U Marine repair standards, Treatment Standard n u Not applicable. Comments: 6C. WATER SYSTEM The water system was evaluated by staff the following determination has been made: u 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. ^i The water source is a public water system that appears to be in substantial compliance with applicable regulations. Comments: . • •• . • • • • • i . • • • •Findings and determinations of this ref tect observed conditions as they 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 WX DATE H:WN-SITE\EHREVIEW.W Revision 01/07/96