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Home My WebLink AboutCRT97-0210 - CRT Application - 12/16/1997 r&s Development, Inc. Chock Mills T OF HEALTH SERVICES - I<md Development 2609 3581h Cl. South -Construction Roy, WA98580 n_yo, e Cons-Imnt POST OFFICE BOX I666 Phone and FAX SHELTON WA 98584 (360) 458-6804 PWO) 427-9670 FAX 42 7-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW Receipt No: rl Date of Payment: I V l 7 1ri D Se tic Water Revi ( 62) : I Both DEC 1 61997 Property Evaluation ($62+$45/Hr) : INSTRUCTIONS PERMIT ASSISTANCE CENTER V�1 11 • oz► 0 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 i hour of work, the department will charge the applicant an additional hourly rate of $40/hour as set fort.ryry,by the Mason County Board of Health. pLz F�x `moo '12cru C(LA�� nL rzr - yap-l�� - S4j// PART 1: APPLIC 4 /PA CEL IDENTIFICATION Avi-N- t_I � �)�zl \, NAME OF APPLICANT �/.1`C TELEPHONE _(.?06 ) 870 - /3 57 SITE/HOUSE ADDRESS_ Y3 jt __ Lam} MAILING ADDRESS �6�� /` �� c.5 /✓O/mac S 77y L, s/f'/a„`�F S (� 'a� . /9 h' ACREAGE Y� 3 d �PR ASSESSOR'S PARCEL NUMBER �- ,L _ / c/ LEGAL PROPERTY DESCRIPTION z2 e Or S'c A/�- T/e SUBDIVISION (If Applicable) DIV BLK _ LOT DIRECTIONS FOR LOCATING SITS _��'o1S' L ,Lt. r //jO,z C . Sketch location of property in this"apace. <f2 C e�c� I I I H:%0N-sXT6l EKREVIEw.W Revfelon 01/07/96 PART 2: PURPOSE OF APPLICATION 2A. OPTION ONE Sd I am applying for a bank loan and the bank has asked for an evaluation of the following: �! Septic System (Fee: S62) Age of System Age of Hoyse e, • Number of Bedrooms 7� • Name of Last Owner • Is house currently occupiedt des o • Attach pumper's report, dated within lest 3 years, stating whether the system was pumped, the size and condition of the tank, and the condition of the baffles. n LJ Water System (Fee: S62) n, • Nurber of service connections on water system • If public water system: Name ot system n L_I Both.(Fee: $100) WH Numoer • Provide information shown above for both septic and water systems 213.. OPTION TWO L I am applying for a building permit, and environmental health has required an evaluation of the following: n L_I Existing Septic System (Fee: $62) • Age of System • Number of Bedrooms • Name of Last Owner • Is house currently occupied? -T—es _ro— • 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.. • If the original septic permit cannot be located and system teas than 5 years old, apply for new On-Site Sewage Disposal Permit. • if the ortgfrKt septic permit cannot be located and system more than 5 years old, submit signed as-built drawing from certified designer or professional engineer. n. u Reserve Area for Future System Repair (Fee: $62) _ • Two properly excavated pits are 4 ft deep mast be ready for inspection by the department. - n u Both (Fee- S62) - • Provide information shown above for both septic system and reserve area 2C. OPTION THREE I am interested in )mowing 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+I0R-SZ7a1f71RlY1'aw.w Revlalan 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. I I I I I I I I r, � I i I j I I I' I II I I I I PART 4: AUTHORIZATION APPLICANCi�-� � DATE G� �2— ��.�✓ �p�r N:\ON-SITE%ERRBVrEW.w ReviaiW 01107196 PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY 5A. DETERMINATION OF APPLICABLE STANDARDS The primary drainfield area aunt meet the following standards: n n LJ Meet current standards LJ Standard marine system n No overt failure LJ Not applicable. The reserve drainfield area must 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 n LJ Meet marine expansion standards. L-1 Not applicable. 5B. WATER SYSTEM t� YES NO INDIVIDUAL WATER SYSTEM n n LJ u A water sample was taken by health department staff and analyzed. Total colifom bacteria were determined to be absent. Laboratory results are attached to this report. n n LJ u The well cap was inspected. The sanitary seal appears satisfactory. n n LI LJ The well casing was inspected. The casing projected above ground 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 n n LJ LJ Records indicate water sampling requirements are being satisfied. n n LJ LJ Records indicate the Water Facility Inventory form is current. n n LJ LJ Department files contain no information indicating the system is out of compliance with state or local water system requirements. 5C. SEPTIC SYSTEM YES FO T n u The septic tank was inspected by a certified septic tank pumper within the past 3 years and fond to be in satisfactory condition. A pumper's evatuatioi is attached to this report. n LJ Records for this property contain a septic permit, design (if required), final inspection approval, and as-built approval. n LJ The drainfield site was inspected, and appears consistent with recorded documents. [7l n lX1 U The drainfield area appears to be maintained in an acceptable manner. IpI n L.s LJ The drainfield area (the area where the drainfie(d is assumed to be located based on office records and/or observed site conditons) appears to be maintained in an acceptable mamer. n u The drafnfield area (the area where the drainfield is assumed to be located based on office records and/or observed site condito s) show no indication of overt faiture at the time of inspection. N:%0N-SITEIENREVrEW.w Revision 01107196 5D. SOIL CONDITIONS TEST HOLE #1 TEST HOLE #2 TEST HOLE #3 1 Depth of root pen. : _ Depth 6f root pen. : _ I/epth of root pen. : _ Depth to restr. layer Depth to restr. layer to restr. layer Soil Type: Soil Type: Soil Type: Vertical Separation:A Vertical Separation:A Vertical Separation:A CurtaVrainable?SlopeShorelMinimuDesign A Vertical separation is the depth of aturated, orkp 1, undisturbed soil of Types 2-6 that exists between the bottom of the subsurface abso ion system and a rictive layer or the waterteble. Vertical separation or es of desk natk desk r. level will be calcul ed by the health department based on a 12-inch deep 5E. OTHER NOTES AND Comm/ R:low-srrzlEFfRsvxsw.w Revtalon 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 LJ The system appeared to be functioning adequately at the time of inspection and and meets current design standards. O-J The system, appeared to be functioning adequately at the time of inspection. 11 Not applicable. Comments: 68. RESERVE DRAINFIELD XREA The reserve drainfield area was inspected by staff and the soil was evaluated. Site characteristics indicated arn_area exists that could support a septic system that would meet the following standards: I-1 Current standards. l'l tJ Marine expansion standards. t1 U Marine repair standards, Treatment Standard I-1 u Not applicable. Comments: 6C. WATER SYSTEM The water system was evaluated by staff the following determination has been 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. u The water source is a public water system that appears to be in substantial compliance with applicable regulations. Comments: • • • • • • •Findings•and determinations of this reviewreflect 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. j Resource land and critical area checklist may be required by Department of Community Development prior to issuance of developmental permit. ...................................... ............................................................................................................................. INSPECTO DATE H:%ON-SITE%MREVIEw.w Revi Si on oJ107196