The URL can be used to link to this page

Home My WebLink AboutCRT2001-00133 - CRT Application - 7/26/2001 4 ITiVIASOPO� OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTON, WA 98584 �� q$S�STANGF (%pi Fk (360) 427-9670 p FAX 427-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW Receipt No: ` / y _ I m Date of Payment: �7— 7 -13 septic or Water Review Bo ($100) : Property Evaluation ( + 0/Hr) : INSTRUCTIONS /r n-(7 �-(,� _D� 13 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 1 hour of work, the department will charge the applicant an additional hourly rate of f50/hour as set forth by the Mason County Board of Health. C _ f7%1 ` C_ � GCX PART 1: APPLICANT/PARCEL IDENTIFICATION 3 �� I NAME OF APPLICANT kk Q M V TELEPHONE SITE/HOUSE ADDRESS M&ILING ADDRESS ACREAGE City State Zip / ASSESSOR'S PARCEL NUMBER �2_ LEGAL PROPERTY DESCRIPTION SUBDIVISION (If Applicable) DIV BLK LOT DIRECTIONS FOR LOCATING SITE n ISk=etchloc.a.tion of property in this space. r}- r cn, l H:\ON-SITE\EHREVIEW.W Revision 2126199 Page 1 PART 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: n - � v Septic System (Fee: E85) • Age of System � - Age of House Number of Bedrooms .� 7 (� L • New of Last Owner C) �(� J[i • Is house currently occupied? Yes No Attach punper'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 LJ Water System (Fee: E85) Number of service connections on water system • If public water system: Name of System Oth (Fee: E100) WFI Number Provide information shown above for both septic and water systems 2B. OPTION TWO I—I LJ I am applying for a building permit and environmental health has required an evaluation of the following: n LJ Existing Septic System (Fee: $85) Age of System • 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. 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-bui It drawing from certified designer or professional engineer. n LJ Reserve Area for Future System Repair (Fee: $85) • Two properly excavated pits are 4 ft deep must be ready for inspection by the department. n LJ Both (Fee: E85) Provide information shown above for both septic system and reserve area H:\OH-SITE\EHREPIEV.w Revision 2126199 Page 2 2C. OPTION THREE ' n U I am interested in knowing in general terms the suitability of a parcel for septic system placement. (Fee: $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 detailed plot plan is onit 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. N PART 4: AUTHORI'26�2�TIO G --�1� APPLICANT DATE H:\0N-SITE\R6Eb Ibw.W Revision 2126199 Page 3 PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY 5A. DETERMINATION OF APPLICABLE STANDARDS The primary drainfield area must meet the following standards: n n LJ Meet current standards LJ Standard marine system �+ n Jul No overt failure U Not applicable. The reserve drainfield area must have site characteristics that could support a septic system that would meet the following standards: _ n n u Meet current standards- LJ Meet marine repair standards. n may/ LJ Meet marine expansion standards. J� Not applicable. 5B. WATER SYSTEM ^/(\YYES NO INDIVIDUAL WATER SYSTEM (�7/mil A water sample was taken by health department staff and analyzed. Total coliform bacteria were determined to be absent. Labpratory results are attached to this report. r1 ��Aln.X-0 ed rU l l 101 -4 JCo'-0 1190 LJ The well cap was inspected. The sanitary seal appears satisfactory. n U The wail casing was inspected. The casing projected above ground and ground was sloped away from the casing. n u 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 700 foot radius of the well. PUBLIC WATER SYSTEM n n u u Records indicate water sampling requirements are being satisfied. n n LJ U Records indicate the Water Facility Inventory form is current. n n lJ LJ Department files contain water system design and letter of approval? 5C. SEPTIC SYSTEM YES NO n LJ %The septic tank was inspected by a certified septic tank pumper within the past 3 years and found to be in satisfactory condition. A pumper's evaluation is attached to this report. FL % Records for this property contain a septic permit, design (if required), final inspection approval, and as-built approval. n u The drainfield site was inspected, and appears consistent with recorded documents. n u L14NN The drainfietd area appears to be maintained in an acceptable manner. re L_I 19 the 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 roamer. n u The drainfield area (the area where the drainfield is assumed to be located based on office records and/or observed site conditons) show no indication of overt failure at the time of inspection. N:ION-SIT&IEaREVIEW.W Revision 2126199 Page 4 5D. SOIL CONDITIONS TEST HOLE #1 TEST HOLE #2 TEST HOLE #3 Depth to restr. layer Depth to restr. layer Depth to restr. layer Soil Type: Soil Type: Soil Type: FINDING SCORE ' Soil Type: Soil Depth: Slope: Parcel Size: Distance to Shoreline: SE. OTHER NOTES AND COMMENTS H:WX-SITBMP9V1EW.W Revision 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: n U The system appeared to be functioning adequately at the time of inspection and and meets current design standards. r1 tJ The system appeared to be functioning adequately at the time of inspection. r1 LJ Not applicable. I c-�� Comments: L d h oW Ct LIAI( 0� A/ o 68. 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: lJ Current standards. n o� tJ Marine expansion standards. n U Marine repair standards, Treatment Standard 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. n u The water source is a public water system that appears to be in substantial compliance with applicable regulations. Comments: .lLt.,., -11 4 .l�c . & 6) dd 'o i"q Sr- ,rsGz� oSCU i(C,G c�y' C ulk... i..ks s ...� -sl... x. :: :::::::::................................................................................ .... ...............::......... .................... ... . .. .................................................................................. .......................::::::. 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. //Pu-r Lo t'jLgt- . 74, rA,-,P l P.LZI/ Resource land and critical area checklist may be required by Department of Comiunity Development prior to issuance of developmental permit. INSPECTOR L ��" DATE N:\ON-SITS\ERA IEW.W Revision 2126199 Page 6