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Home My WebLink AboutCRT99-0125 - CRT Application - 7/30/1999 i MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTiON, WA 98584 (360) 427-900 FAX 427-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW Receipt No: I Date of Payment: _ j I 1 Septic or Water Revi�($e Hot �+ So/ur) : '_ Property Evaluation ��-- _ I INSTRUCTIONS 1. An applicatton is considered coaplete when the fee is paid, Parts 1-4 of the applteeften form are completed. (assistance will be provided upon request for coapleting 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 S50/hour as set forth by the Mason County Board of Health. PART 1: APPLICANT/PARCEL IDENTIFICATION NAME OF APPLICANT, 042,,ez� ��A / QF eCJ� TELEPHONE SITE/HOUSE ADDRESSq /e,1;07 IYIIJ ISel5ei /'\� fWLIM ADDRESS \.J//'2.!/C) _ GU.Fi, ii�e.7n., �Sffel ACREAGE �. 5' / C ty state zip ASSESSOR'S PARCEL N@18ER LEGAL PROPERTY DESCRIPTION SOSDMSION (if Applicable) ,,C — '— IV BLK LOT _ DIRECTIONS R LOCATING SITE O / /!J l Nh eft onrJlay., co ✓ [i // 771 nl % kelsrsJ 7'r�r ryh� i 7 . O I Sketch location of property in this space. I I I I I I I I ( I NrlgY-SZ=%EKREWEV.w Revtaloa 2126199 P,Se 1 PART 2: PURPOSE OF APPLICATION A. OPTION ONIi lJ I am applying for a bank loan and the bank has asked for an evaluation of the following: r-i L_I Septic System (Fee: $85) • Age of System ` • Age of House • Number of Bedrooms • Name of Last Owner ( • Is house currently occupied? Yes No • Attach pumper's report, dated within last 3 years, stating whether the system was pumped, the size and condition of the tank, and the condition of the baffles. n tJ Hater System (Fee: $95) • Number of service convections on water system • If public water system: xanme of system wFI Number Both (Fee: $100) Provide information shown above for both septic and water systems 213• OPTION TWO lJ I am applying for a building permit and environmental health has required an evaluation of the following: n IJ Existing Septic System (Fee: $85) • Age of System • Number of Bedrooms • Name of Last Owner • Is house currently occupied? - Yes No • Attach puaper's report, dated within last 3 years, stating whether the system was pumped, 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 carrot be located and system more than 5 years old, submit signed as-built drawing from certified designer or professional engineer. i"n IJ Reserve Area for Future system Repair (Fee: $85) • Two properly excavated pits are 4 ft deep nut be ready for Inspection by the department. n U Both (Fee: $85) • Provide information shown above for both septic system and reserve area w,IOR-SITSISHSEVIEV.w Revlatm 2126195 p,7c 2 2C OPTION THREE lJ I am interested in )mowing in general terms the suitability of a parcel for septic system placement. (Fees $85 base, plus $50/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 detaited plot plan is one that shows the precise location of the test holes, existing septic system, dimensions of the property, and location of any wells, roads, or other buildings on the property. I I I I i I I I I I I I I I I I I I I I I I I I I I I � I Ii �-7 I I �� I I y i3«� k I r I j I � I f hou. i ! PART 4: AUTHORIZATION APPLICANT DATE ! \30-99 N,ION-SYMEFOMWEw•N Revision 2126199 Page PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY SA. DETERMINATION OF APPLICABLE STANDARDS The primary drainf t old area must meet the following standards: n n U Meet current standards LJ Standard marine system n y�Yo overt failure LJ Not applicable. The reserve drainfield area mast have site characteristics that could support a septic system that would meet the following standards: n n LJ Meet current standards. LJ Meet marine repair standards. n LJ Meet marine expansion standards. Hot applicable. 5B. WATER SYSTEM YES 1100 INDIVIDUAL WATER SYSTEM n LJ A water sample was taken by health department staff and analyzed. Total colifonw bacteria were determined to be absent. Laboratory results.are attached to this report. n n tJ u The well cap was inspected. The sanitary seal appears satisfactory. n n LJ LJ The well casing was inspected. The casing projected above grand and ground was sloped away from the casing. n n LJ LJ 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 wr n n u LJ Records indicate water sampling requirements are being satisfied. n n LJ LJ Records indicate the Water Facility Inventory form is current. n n U LJ Department files contain water system design and letter of approval? 5C. SEPTIC SYSTEM YES Ij_0 pi n �2 LJ The septic tank was Impacted by a certified septic teMc puiper within the past 3 years and fond to be �(y in satisfactory condition. - A pumper-s evaluation is attached to this report. AC n L-i Records for this property contain a septic permit, design (if required), final inspection approval, and as-built approval. n n U U The drainfield site was impacted, and appears consistent with recorded documents. n n LJ LJ The drainfield area appears to be maintained in an acceptable manner. e) n lJ The drainfield area (the area where the drainfield is assumed to be located based on office records and/or observed site eondttons) appears to be maintained in an acceptable roamer. n LJ The dra infield area (the area where the drainfield is assumed to be located based on office records and/or observed site conditios) show no indication of overt failure at the time of inspection. R:ia1-sX7RiE7azEVT9w-w Revision 2126199 page 4 5D. SOIL CONDITIONS TEST HOLE #1 I TEST HOLE N2 I TEST HOLE #3 I I I I j j I 1 I I I I I I I I I I I I I I I I I I I Depth to restr. layer I Depth to restr. lays I Depth to restr. layer Soil Type: I Soil Type: I Soil Type: I I I I INDING SCORE I I Soil Type: I I I Soil Depth: I I I Slope: "� I I I Parcel Size• I I I I Distance o Shoreline: I I I 5E. OTHER NOTES AND C6mi S H:%ON-SIMEMP ZEW.M Revlslm 2126199 Page 5 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 was made: U The system appeared to be functioning adequately at the time of inspection and 1y1 and meets current design standards. The system appeared to be functioning adequately at the time of inspection. n l_J 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: 1-1 u current standards. n tJ Marine expansion standards. f'l 11l t Marine repair standards, Treatment Standard Y�1 Not applicable. 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. t1 tJ The water source is a public water system that appears to be in substantial compliance with applicable regulations. Comments: — ............................ ......... .................................................... . :...:: .................................................................................. ........................... ..................... ........................... ............................................................ ..................................... 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 Coamnity Development prior to issuance of developmental permit. INSPECTOR DATE X:\�R-SITE\ERREVId.w Revision 4199 Page 6