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HomeMy WebLinkAboutCRT94-0072 - CRT Application - 3/24/1994 MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTON, WA 98584 (206) 427-9670 FAX 427-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW Receipt No: M D Date of Payment: MAR 2 4 S94 Septic Review: Water Review: ILTH SERVICES Property Evaluation: SERVICES INSTRUCTIONS -C-)J� 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 project requires the excavation of more than 3 test holes, the department may Charge the applicant an hourly rate of.$3'7/hour as set forth by the Mason County Board of Health. PART 1: APPLICANT/PARCEL IDENTIFICATION NAME OF APPLICANT4 4 r-AP S L' Lr/f}LKC e TELEPHONE (wb ) qZ>- 6 06 9 SITE/HOUSE ADDRESS j- LIMlL d JL La.nE— MAILING ADDRESS PU �X / �C �.� // S- 1,6� w Q y ACREAGE I �f Cy y Ht sta Ziy ASSESSOR'S PARCEL NUMBER 3.2/36 =I 9'O ©g'0 LEGAL PROPERTY DESCRIPTION LE / BLK 2 .SL G 36 wQ 3M S/+a 't i5t,+ Jf 3L1 SUBDIVISION (If Applicable) DIV BLR _ LOT DIRECTIONS FOR LOCATING SITE /p ,w '/-e A/ 5744 160t- 44/ w y 3 - �e P-F o-E 7e, iN I/Q GOSL- C70o o� b // Post v er Cra K Std2E� /r�/ cr,i/a iti Cs , L a.F& C z tuahll 1a5-) / Sketch location of property in this space. PART 1 2: PURPOSE OF APPLICATION ............................ ..................... .................... . ................. .............................................................................................................................. 2A. OPTION ONE I am applying for a bank loan and the bank has asked for an evaluation of the following: El septic s;� (F- ee: $50) �� • Age Of cyst i • Age of ECUs • Number of BedIMMU11 • Name of Last Owner • Is house currently occu ? • Attach pumper's sport, dated within last 2 years, stating whether the system was pumped, the size and condition o the tank, and the condition of the baffles. Dwater Sy (Fee: $40) umber of service connections on water system If public water system: 0 Both (Fee: $68) • Provide information shown above for both septic and water systems 2B. OPTION TWO )ftak;l, XI am applying for a building permit, and environmental health has required an evaluation of the following: Existing Septic System (Fee: $50) • Age Of System • Number of Bedrooms • Name of Last Owner SU TO Vic • Is house currently Occupied? • Attach pumper's report, dated within last 3 years, stating whether the system was pumped, the size and condition of the tack, 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. Reserve Area for Future System Repair (Fee: $40) - Two properly excavated pits are 4 ft deep must be ready for inspection by the department. El Both (Fee: $50) . Provide information shown above for both septic system and reserve area 2C. OPTION THREE 1 am interests knowing in al the suitability of a parcel for septic system placement. + r S371hour) Describe the intended Of the property d 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 toot holes, existing septic systems, dimensions of the property, and location of any wells, roads, or other buildings on the property. el PART FOUR: AUTHORIZATION .............................................................................................................................................................................. APPLICANT DATE PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY .............................................................................................................................................................................. 5A. DETERMINATION OF APPLICABLE STANDARDS The primary drainfield area must met the following standards: nMeet current standards Standard marine system x- overt failure Not applicable. The reserve drainfield area must have site characteristics that could support a septic system that Would meet the following standards: Meet current standards. Meet marine repair standards. Meet marine expansion standards. El Not applicable. 5B. WATER SYSTEM YES NO INDIVIDUAL WATER SYSTEM nEl A water sample was taken by health department staff and alyzed. Total colifo= bacteria were determined to be absent. Laboratory results are a Chad to this report. ElThe I cap was inspected. The sanitary al appears satisfactory. El11 The well casing inspected. casing projected above ground and ground was sloped away from the casing. nn The well site was in. ted. No tic systems, chemical storage facilities, manure piles, animal feed lots, or other obv . sources of cont ation were located within a 100 foot radius of the well. PUBLIC WATER SYSTEM Recor indicate water sampling requirements are being satisfied. El [I ac.,ds indicate the Water Facility Inventory form is current. Department files contain no information indicating the system is Out Of COMPliauCe with state or local water system requirements- 5C. SEPTIC SYSTEM NO ElThe septic tank was inspected by a certified septic tank pumper within the past 2 years and found to be In satisfactory condition. A pumper's evaluation is attached to this report. El m UD�Racorda for this property contain a septic permit, design (if required), final inspection approval, and an-built approval. ElThe drainfield site was inspected, and appears consistent with recorded documents. ElThe drainfield area appears to be maintained in an acceptable manner. ElThe 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. nThe drainfield area (the area where the drainfield is assumed to be located based cn office records and/or observed site conditcns) show no indication of Overt failure at the time of inspection. 5D. 'SOIL CONDITIONS TEST HOLE #1 TEST HOLE #2 TEST HOLE #3 Depth of root pen. : Depth of root pen. : Depth of root pen. : Depth to restr. layer Depth to restr. layer Depth to restr. layer Soil Type: Soil Type: Soil Type: Vertical Separation:" Vertical Separation:' Vertical Separation:' _ Curtain drainable? (Y/N/NA) : Slope (%) : Shoreline? (YIN) : Minimum lot size:' Designer level: ' vertical separation is the depth of unsaturated, originale undisturbed soil of Types 2-6 that exists between the bottom of the subsurface absorption system and a restrictive layer or the watertable. vertical separation for purposes of designating designer level will be calculated by the health department based on a 12-inch deep 5E. OTHER NOTES AND COMMENTS ZT i B- S If o0AIr v ,/ 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: The system appeared to be functioning adequately at the time of inspection and and meets current design standards. K'The system appeared to be functioning adequately at the time of inspection. El 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. Marine expansion standards. Marine repair standards, Treatment Standard ❑ Not applicable. ,. r n� p /�� Comments: � l &CL' Gel-- Y s I,YN�- IW T-4- �✓LO t '/Gn i - L� L 6C. WATER SYSTEM The water system was evaluated by staff the followin urination has been made: The water source sists of an in ua1 well that appears to be a satisfactory source o otab ester for a single family residence. The water was sampled, and colifo eria were found to be absent. The water sour is a public water system t appears to be in substantial compliant i.th 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 chec t e required by Department of Community Development prior to Ssauance of developmental permit. INSPECTOR DATE . Qo � U O� M 1 T I v h v x anid'D ??A i 0 i o 4 � 3 , o - i w w w rl V IV t- Q_ I j v • iiPEE'.r � � ^A .� 0 0 o H� 0 p C 4�s s b �^ Z h � ` yo � U � rl - A J� c ov\ Z ni c � 11 � � n w b o � a - �n o i n ��