HomeMy WebLinkAboutSPH93-1086 - SPL Application - 11/17/1993 MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SHELTON, WA 98584
(206) 427-9670
FAX 427-8425
APPLICATION FOR SHORT PLAT EVALUATION
Receipt No:
INSTRUCTIONS S _ Ot St,,, Date of Payment:
1. An application is considered complete when the fee is paid and the following elements have been addressed:
• Parts 1 and 2 of the application form must be completed.
• One properly excavated backhoe pit per proposed parcel must be ready for inspection. Properly excavated pits
are 6 It deep with a 4 It deep shelf on one end of the pit. The 4 ft deep shelf must slope up to the ground
surface for easy ingress and egress.
• A scaled plot plan must be attached to the application. The scaled plot plan must 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 It of the property boundaries.
2. After a completed application is received, staff will inspect the property and provide the applicant with a
written report. If the project requires more assistance than the evaluation of four test holes and completion
of this report, an hourly rate of $37/hour as set forth by the Mason County Board of Health may be charged to
the applicant. Revised 09/01/92
PART 1: APPLICANT/PARCEL IDENTIFICATION 3213(r-Zy-ld0(9l
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• NAME OF APPLICANT ( �I • TEL
(_ 7��a NFL --I Cr CI L
V) 6s30L
• MAILING ADDRESS ( -1 W L4 i I C Z"Ca G - _ <'•
C StY S<�ta rig -'
L4 -3
• ASSESSOR'S PARCEL NUMBER
• LEGAL PROPERTY DESCRIPTION F� 11.2 �S% \/`� S �/ K� ` 4
• LOT SIZES CRE OR SQ FT) S -?V 3- -Z� -Z•-�`�
Lot 1 L.ot 'S n Let 3 LeG 4
• DIRECTIONS FOR LOCATING SITE Q,�Q C6. 1 r
C
PART 2: INTENDED USE OF PARCEL Lq� 911
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• INTENDED USE OF PROPERTY (Check One) :
'gle family residence Multi-family residence
Other, specify:
• WA 7
ER SOURCE FOR PARCELS (Check One) :
Individual wells Community well
M-1
Revised 03/04/93
Shout: Plat Evaluation
PART 3: HEALTH DEPARTMENT REVIEW (OFFICIAL USE ONLY)
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SOIL LOGS AND SITE CHARACTERISTICS
LOP f LOT A LOT # LOT
Test Pit A Test Pit A Test Pit A Test Pit A
C—OLI"
5 4-d
_toet fo 2CA
Depth of root pen.: -1 Depth of root pen.: Depth of root pen.: Depth of root pen.:
Depth of mottling: Ct, Depth of mottling: Depth of mottling: Depth of mottling:
Depth to rest. layer: A�l Depth to rest. layer: Depth to rest. layer: Depth to rest. layer:
Soil type (USDA): Soil type (USDA): Soil type (USDA): Soil type (USDA):
Test Pit B Test Pit B Test Pit B Test Pit B
Depth of root pan.: Depth of root pen.: Depth of root pen.: Depth of root pen.:
Depth Of mottling: Depth of mottling: Depth of mottling: Depth of mottling;
Depth to rest. layer: Depth to rest. layer Depth to rest. layer: Depth to rest. layer:
Soil type (USDA): Soil type (USDA): Soil type (USDA): Soil type (USDA):
curtain drain needed? curtain drain needed? curtain drain needed? curtain drain needed?
Slope (%): Slope (%): Slop. (%): Slope (%):
Shoreline? (YIN): Shoreline? (YIN); Shoreline? (YIN): Shoreline? (YIN):
Minimum lot size:' Minimum lot size:' Minimum lot size:' Minimum lot size:'
Minimum lot size applies to new subdivisions and is defined as the minimum allowable land area per residence or residen-
tial equivalent (450 gallons per day).
COMMENTS
FJ(5 A
44y
WIA 1AM LN'qt _%ij
oly?,A,
Revised 03/04/91
. Short plat Evaluation
PART 4: HEALTH DEPARTMENT REVIEW SUMMARY (COMMUNITY DEVELOPMENT USE)
MEETS HEALTH CODE
fter 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.
® 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 regulations until the following conditions are met:
ElCondition(e) required prior to approval have been met by the applicant.
Health Official Date
PART 5: REVIEWER SIGNATURE
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Health Official Date
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