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Home My WebLink AboutSPH93-0186 - 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 qq ��/ Receipt No: alC L INSTRUCTIONS S _ (fir 9-,4, 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 ft deep with a 4 ft 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 Hoard of Health may be charged to the applicant. Revised 09/01/92 PART 1: APPLICANT/PARCEL IDENTIFICATION 32i3�-� • NAME OF APPLICANT C T� • TELEPHONE (-_}{,a 4{,).L -.2 '=1_Cf (:1�7 ( +ramI rp)(A�, � �(ssoL • MAILING ADDRESS ( �I (,,`� L ,i I C Z; a d t G_ Ye tnn ( 1 c icY Scats ZSy -' y c� 3 u • ASSESSOR'S PARCEL NUMBER �yyJJ� .3 �o ,j - - LL JQ_� • LEGAL PROPERTY DESCRIPTION ►Sb 1�.2 SLR \/ / S (I..2 Nls-) 1/4 • LOT SIZES CRE OR SQ FT) t 1 LeC 2 Lot 3 Lot 4 • DIRECTIONS FOR LOCATING SITE C PART 2: INTENDED USE OF PARCEL ....................................................................................... ................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................... . • INTENDED USE OF PROPERTY (Check One) : v� Vi gle family residence Multi-family residence er, specify: • WA 7 ER SOURCE FOR PARCELS (Check One) : Individual wells Community well M-1 Revised 03/O4/91 Short Plat Evaluation PART 3: HEALTH DEPARTMENT REVIEW (OFFICIAL USE ONLY) .............................................................................................................................................................................. SOIL LOGS AND SITE CHARACTERISTICS LOT 4 un # _ LOT # LOT I Test Pit A Test Pit A Test Pit A Test Pit A C_caot4 5 rock fo2ci Depth of root pen.: -1Depth of root pen.: Depth of root pen.: Depth of root pen.: Depth of mottling: TC-18 Depth of mottling: Depth of mottling: Depth of mottling: I 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): Test Pit B Test Pit B Test Pit B Test Pit B Depth of root pen.: 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? Curtsin drain needed? Curtain drain needed' Slope (%): Slope (%): Slope (t): Slop. (%): 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 N1(3 Ac� L_& Mvt OL^ Or 112, t6'kl f2 QeQA4-V 4, D- Wvll ledd LA,04 AUt i-,KnwVVN S\IQ V-QaA4N� -%li :y9t . Akm, t" QAVCIs 40 bt AkAN Bevis cd 03/04/91 Short Plat Evaluation PART 4: HEALTH DEPARTMENT REVIEW SUMMARY (COMMUNITY DEVELOPMENT USE) ........................... ............................. ........................:::::............................................................................................. ................................................. X)mTS HEALTH CODE Vfter 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. InDOES 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: Condition(s) required prior to approval have been met by the applicant. Health Official Date PART 5: REVIEWER SIGNATURE .............................................................................................................................................................................. 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