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Home My WebLink AboutCRT2006-00040 - CRT Application - 4/4/2006 MASON COUNTY DEPARTMENT OF HEALTH SERVICES 426 W CEDAR ST., PO BOX 1666, Shelton WA 98584 SHELTON (360) 427-9670 Ext: 352 ELMA (360)482-5269, BELFAIR (360) 275-4467 WEB: http:ilwww.co.mason.wa.us FAX: (360)427-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW PERMIT NUMBER PAYMENT INFORMATION TYPE OF REVIEW Receipt Number: S1200600000000001289 CRT2006-00040 Payment Type: Check Septic&Water Date of 04/04/2006 Important Notice: Findings &determinations of this review reflect observed conditions as they existed on the day the evaluation was preformed. Absolutely no claim is made by this office, expressed or implied concerning the future success, failure or permit approval of the system and site evaluated. ** FILL OUT APPLICATION COMPLETELY AND ACCURATELY"* An application is considered complete when the The is paid, parts 1, 2 and 3 of this application form are completed, necessary paperwork is attached (i.e. pumpers report)and when required, soil evaluation holes have been excavated. PART 1. APPLICANT PARCEL IDENTIFICATION Applicant: WENDY FREEDMAN Telephone: 360-432-0102 Mailinq Address: C/O JC NOWACKI E 1982 HWY 3 Citv: SHELTON State: WA Zip: 98584 Parcel Number: 321352290011 Site Address: 1012 E MIKKELSEN RD SHELTON Brief Legal Description: TR 1-A OF NE NW NW LOT: 1 OF SP #2172 Driving Directions: FROM TOWN TAKE HWY 3 NORTH TO MASON LAKE DRIVE, TURN LEFT, GO UP MASON LAK DRIVE TO MIKKELSEN ROAD, TURN RIGHT, FOLLOW MIKKELSEN ROAD 9/10 MILE TO FORK. TAKE LEFT FORK. GO 2/10 MILE TO PROPERTY CORNER PART 2. TYPE OF REVIEW Septic System Age of system: 10/26/1993 Age of house: 13 Number of bedrooms: 3.00 Name of last owner: FREEDMAN Is house currently occupied?: Vacant If not occupied, how long has it been vacant?: 1 MONTH Water System Number of service connections on the water system?: If a public water system, name of system: WFI number: Proprety Evaluation (soil logs) Property evaluations provide, in general terms, the suitability of a parcel for septic system placement. THIS DOES NOT GUARANTEE FUTURE SEPTIC SYSTEM APPROVAL. Describe the intended use of the property and the reason for requesting the review The description of the intended use is not included in this report. PART 3. PLOT PLAN Use the space below to draw a detailed plot plan, or attach a detail plot plan to this application. The plot plan should include the following: North Arrow, Precise Location of Test Holes, Location of Existing Septic System, Dimensions of Property, Location of any Drinking Water Sources (wells, springs, etc), Roads, Easements, Surface Water, and Buildings on the Property. LOT SIZE x Acres The applicants plot plan is not included in this report. Applicant Signature: Signature is not included in this report. Date: The date is not included in this report. CRT2006-00040 2 of 4 PART 4. HEALTH DEPARTMENT FINDINGS -- OFFICIAL USE Septic System Y The septic tank was inspected by a certified septic tank pumper within the last 3 years and was found to be in satisfactory condition. A pumpers report is attached. N Records for this property contain a septic permit, design, final inspection approval and an as-built drawing. N The site was inspected and the system location appears to be consistent with recorded documents. Y The area of the on-site system appears to be maintained in an acceptable manner. N Was Operation and Maintenance a condition of permit approval? Is a copy of current Operation and Maintenance report attached? Water System Individual Water System Y A water sample was taken by health department staff and analyzed. Total coliform bacteria were determined to be absent. Laboratory results are attached to this report. Y The well cap was inspected. The sanitary seal appears satisfactory Y The well casing was inspected. The casing projected above ground and the ground was sloped away from the casing Y The well site was inspected. No septic systems, chemical storage facilities, manure piles, animal feedlots or other obvious sources of contamination appeared within 100-foot radius of the well. Public Water System Records indicate water-sampling requirements are being satisfied. Records indicate the Water Facility Inventory form is current. N Department files contain water system design and letter of approval Soil Conditions Test Hole #1 Test Hole #2 Test Hole#3 Soi I Type Soi I Type Soi I Type Restr. Layer Restr. Layer Restr. Layer Slope Slope Slope Distant to Shoreline Distant to Shoreline Distant to Shoreline CRT2006-00040 3 of 4 PART 5: HEALTH DEPARTMENT OBSERVATIONS -FOR OFFICIAL USE ONLY Primary Drainfield Staff inspected the primary drain field area and when available, pertinent records were reviewed. The following determination was made Y The system appears to be functioning adequately at the time of the inspection. (only applicable if system has been in use on a regular basis for the last 6 months) N Sanitary Survey? Survey Results Water System Staff evaluated the water system and the following determination was made Y The water source consists of an individual well the appears to be a satisfactory source of potable water for a single-family residence. The water was sampled and coliform bacteria were absent. The water source is a public water system that appears to be in compliance with the applicable regulations Well Construction Permit Permit Status PART 6: COMMENTS Water Review: Lab # 05600546 on 4/12106 satisfactory Septic Review: A 1993 permit is on file but an asbuilt drawing was never received. The area of the drainfield proposed in the design document show no overt failure and has been mowed. A satisfactory pumpers report was submitted. Although the installation was inpected and approved for cover, records are not complete without an asbuilt. INSPECTOR �� DATE �f�law(P �— Important Notice: Finding determinations of this review reflect observed conditions as they existed on the day the evaluation was preformed. Absolutely no claim is made by this office, expressed or implied concerning the future success, failure or permit approval of the system and site evaluated. CRT2006-00040 4 of 4 MASON COUNTY DEPARTMENT OF HEALTH SERVICES 426 W CEDAR ST.,PO BOX 1666, SHELTON,WA 98584 SHELTON(360)427-9670,Ext: 352, ELMA(360)482-5269, BELFAIR(360)275-4467 WEB: httu://www.co.mason.wa.us FAX:(360)427-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW PERMIT NUMBER PAYMENT INFORMATION TYPE OF REVIEW CRT Receipt Qumber 'Septic and Water $250�E1 RECEIVED 00�0 ❑ Cash ❑ Septic $150 a Onto Check ❑ Water $150 APR 0 4 2006 Date of Payment �3c ' ❑ ResamPropertyE $181ab e MASON COUNTY ❑ Resample $181ab fee Important Notice:Findings&determinations of this review reflect observed conditions as they exist on the day the evaluation was preformed. Absolutely no claim is made by this office, expressed or implied concerning the future success,failure or permit approval of the system and site evaluated ****FTLL OUT APPLICATION COMPLETELY AND ACCURATELY**** An application is considered complete when the fee is paid,parts 1, 2, and 3 of this application form are completed, necessary paperwork is attached(i.e. pumpers report) and when required soil evaluation holes have been excavated. j� PART 1. APPLICANT/PARCEL 11)& I ATI11O S U ��✓ � Name of Applicant ` d d)^ Telephone 2 2 Mailing Address of Applicant City kd42 State "(!(// f Zip Jd 12-digit Tax Parcel No.��11� Site Address I y t P C/ Brief Legal Description tam Driving Directions S �-- C405 <� Page 1 of 4 QQ 04/03/2006 16:00 NO 649 D01 _ . __ rnw oVu •,j+ �'7 R'{�l,i/.,; I tajj,{'.tTr'1'� �� }%4�_, , -'AUT26 'TYBYCOFRF' ❑ septic • Age of syBt" • Age ofbou" ..1 • Nnmber of baboolo =I • .Y�Y9gte of IB�tEow" •e' r� m ;,y, i , • Ys house eurnady oqc H, 1 it ' d • Yam occupied,how long ifs �y1 Ca 'Water system � L�4 ,, , fl.• r" ;.. i NUMber of90[vlce ro • If s public water aye on(uu.lboa) trap"rwwwil Property ovatuagow pleat• TFliS u01�51 NOT( C1s + T ►, 't �'! 4ibo the inteatded•use of its *sh0A P&W 3: PIsa+ri t .` ee the space btdowtvdraw,ad ; i' : The plot pl�a.Pald'h1 uie'tl0 ( f pipe to pplicatlou. ��S o, awwbn of c ads, R: ,.of Sources !Ais- +, ��` �NI` 1. •.�R,•' t,�• + 1� _ ',kilt!{I✓ 1 I:. Paga20t4 a iF 'tit IRLP PART 4: HEALTH DEPARTMENT FINDINGS—OFFICIAL USE ONLY Septic System Yes No ❑ ❑ The septic tank was inspected by a certified septic tank pumper within the last 3 years and was found to be in satisfactory condition. A pumpers report is attached. ❑ ❑ Records for this property contain a septic permit, design, final approval and as as-built drawing. ❑ ❑ The site was inspected and the system location appears to be consistent with recorded documents. ❑ ❑ The area of the on-site system appears to be maintained in an acceptable manner. ❑ ❑ Was Operation and Maintenance a condition of permit approval? ❑ ❑ Is a copy of a current Operation and Maintenance report attached? Water System Yes No Individual Water System ❑ ❑ A water sample was taken by health department staff and analyzed. Total coliform bacteria were determined to be absent. Laboratory results are attached to this report. ❑ ❑ The well cap was inspected. The sanitary seal appears satisfactory. ❑ ❑ The well casing was inspected. The casing projected above ground and the ground was sloped away from the casing. ❑ ❑ The well site was inspected.No septic systems, chemical storage facilities,manure pile, animal feedlots or other obvious sources of contamination appeared within a 100-foot radius of the well. Yes No Public Water System ❑ ❑ Records indicate water-sampling requirements are being satisfied. ❑ ❑ Records indicate the Water Facility Inventory for is current. ❑ ❑ Department files contain water system design and letter of approval. Soil Conditions Test Hole #1 Test Hole#2 Test Hole#3 Soil Type: Soil Type: Soil Type: Restrictive layer: Restrictive layer: Restrictive layer: Slope: Slope: Slope: Distance to Shoreline: Distance to Shoreline: Distance to Shoreline: Page 3 of 4 P,,:a4T`5: HEALTH DEPARTMENT OBSERVATIONS-FOR OFFICIAL USE ONLY Primary Drainfield Yes No ❑ ❑ The system appears to be functioning adequately at the time of the inspection. (Only applicable if system has been in use on a regular basis for the last 6 months.) ❑ ❑ Sanitary survey? ❑ Pass ❑ Fail ❑ Suspect ❑ Not applicable Water System Yes No ❑ ❑ 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 absent. ❑ ❑ The water source is a public water system that appears to be in compliance with the applicable regulations. ❑ ❑ Well Construction Permit ❑ Pass ❑ Fail PART 6:COMMENTS INSECTOR DATE Important Notice: Findings &determinations of this review reflect observed conditions as they exist on the day the evaluation was preformed. Absolutely no claim is made by this office, expressed or implied concerning the future success, failure or permit approval of the system and site evaluated. Page 4 of 4