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Home My WebLink AboutCRT95-0205 - CRT Application - 11/7/1995 MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTON, WA 98584 (206) 427-9670 FAX 427-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW I Receipt No: Date of Payment: Septid -r Water Review ($60) : �� ID 11 D Both ($100) : I u - I Property Evaluation ($40/hr) : INSTRUCTIONS NOV n 6-4s95 G�5 _z�5 1. An application is considered coaplete when the fee is paid, Parts 1-4 of the applicaggft�m`pt�c a /��e (assistance will be provided upon request for completing Part Two), the necessary pape ilist�ttia S/ 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 project requires the excavation of more than 3 test holes, the department may charge the applicant an hourly rate of S40/hour as set forth by the Mason County Board of Health. PART 1: APPLICANT/PARCEL h1ID�E/NTIFICATION NAME OF APPLICANT -R ' CiKQ J / I i VAN DIRTAI TELEPHONE ( 3fPO ) 275-71f86 SITE/HOUSE ADDRESS QJ N tF ROCLA MAILING ADDRESS NE Zu a-1 0. $S2R ACREAGE 3,9Z y y S a1—�� ASSESSOR'S PARCEL NUMBER Z 3 z O - O - O 2- O O_ 1tl' LEGAL PROPERTY DESCRIPTION SUBDIVISION (If Applicable) I51V ' - BLK LOT 20(` DIRECTIONS FOR r�,p�ATING SITE /ale A To, 1 ff / J, fi' $} ,Ji .�.+ � «; fo New: 1r d. r P.J-*6 L ovr. 1rf ii v.,- w,ld+ N�zl He U R,b. Sketch I `pation of property in this space. I X I O:\ON-SITE\EHRGXI .W Revision 22/5/94 PART 2: PURPOSE OF APPLICATION 2A. OPTION ONE f1 L—) I am applying for a bank loan and the bank has asked for an evaluation of the following: n LJ Septic System (Fee: $60) Age of System • Age of House Number of Bedrooms Name of Last owner Is house currently occupied? • Attach pumper's report, dated within last 2 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: S60) - Number of service connections on water system _ If public water system: arce Ot System n WFI Number LJ Both (Fee: $100) Provide information shown above for loth septic and water systems 2B. OPTION TWO I am applying for a building permit, and environmental health has required an evaluation of the following: Apr o Existing Septic System (Fee: S60) Age of System em rS Number of Bedrooms Name of Last Owner To.*+ Vl55el- • Ls house currently occupied? --wo— • 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-built drawing from certified designer or professional engineer. n LJ Reserve Area for Future System Repair (Fee: $60) • Two properly excavated pits are 4 ft deep must be ready for inspection by the department. n LJ Both (Fee: $60) • Provide information shown above for both septic system and reserve area 2C. OPTION THREE n L—I I am interested in knowing is general terms the suitability of a parcel for septic system placement. (Fee: $40/hour) Describe the intended use of the property and the reason for requesting the review: H:\ON-SZTG\EHREVZ EU.F Revision 32/5/94 PART 3: PLOT PLAN Use this space to draw a detailed plot plan, or attach one to this application. A deta shows the precise location of the test holes, existing septic systems, dimensions of th wells, roads, or other buildings on the property. PART 4: AUTHORIZATION ?.r2LICTNT DATE 2 AJ Ur / H:\ON-SITE\EHREXZ -W Revision 1215194 PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY 5A. DETERMINATION OF APPLICABLE STANDARDS The primary drainfieLd area must meet the foltowing standards: n F-1 LJ Meet current standards LJ Standard marine system n r' LJ No overt failure " 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. Lu Meet marine repair standards. n n LJ Meet marine expansion standards. LJ Not applicable. 5B. WATER SYSTEM YES NO INDIVIDUAL WATER SYSTEM LJ LJ 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. n n u LJ The welt cap was inspected. The sanitary seal appears satisfactory. LJLJ The welt 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. LJLnJ Department files contain no information indicating the system is out of compliance with state or Local water system requirements. 5C. SEPTIC SYSTEM YES NO jr n ■{' LJ The septic tank was inspected by a certified septic tank pumper within the past 2 years and found to be nay �1 in satisfactory condition. A pumper-s evaluation is attached to this report. W LJ Records for this property contain a septic permit, design (if required), final inspection approval, and as-bui Lt approval. r � 2 LJ The drainffield site was inspected, and appears consistent with recorded documents. n n u u The drainffield area appears to be maintained in an acceptable mariner. IJ The drainf field area (the area where the drainffield is assumed to be located based on office records and/or observed site conditons) appears to be maintained in an acceptable manner. n LJ The drainffield area (the area where the drainffield is assumed to be located based on office records and/or observed site conditios) show no indication of overt failure at the time of inspection. H:\ON-SZTE\EHRFVZEW.W Revision 1215194 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: 1 U The system appeared to be functioning adequately at the time of inspection and and meets current design standards. X�j The system appeared to be functioning adequately at the time of inspection. r__1 " Not applicable. Comments: 6B. 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: n tJ Current standards. r1 LJ Marine expansion standards. n u Marine repair standards, Treatment Standard n u Not applicable. Comments: 6C. WATER SYSTEM The water system was evaluated by staff the following determination has been made: 1_J 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•review•reflect observed conditions•as they•existed on•the day the evaluation was ••••• performed. Absolutely no ctaim is made by this office, either expressed or implied, concerning future success or failure of the systems and sites evaluated. Resource land and critical area checklist may be required by Department of Community Development prior to issuance of developmental permit. ....................................... .... INSPECTOR DATE H:\ON-SITE%EHREVIEW.W Revision 1215194