HomeMy WebLinkAboutCRT97-0176 - CRT Application - 10/15/1997 ' I
MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SHELTON WA 98584
(31?0) 427-9670
FAX 427-7798
APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW
Receipt No:
I Date of Payment: � ^{ IU7 �C U 11IIVII 11
Septi or Water Review ($62) : — I uu OCT 1 5 0.
Both ($100) :
Property Evaluation ($62+$45/Hr) :
' PERMIT ASSISTANCE CENTER
INSTRUCTIONS .fGi� 0I-1
1. An application is considered complete when the fee is paid, Parts 1-4 of the application fora 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 wilt charge the applicant an additional
hourly rate of S40/hour as set forth by the Mason County Board of Health.
PART 1: APPLICANT/PARCEL IDENTIFICATION
NAME OF APPLICANT \X11/l i 414 Y—. )z L kn 1 C.In nxe l TELEPHONE (360 ),�R 7%S—
SITE/HOUSE ADDRESS A( E Pf.Y.e t R-e-e-
MAILING ADDRESS ME.-al P/n •e_ tIC-2-� �7/.• L
sr, v st__ i1 °�S• EbSyS" ACREAGE
ASSESSOR'S PARCEL NUMBER
LEGAL PROPERTY DESCRIPTION
SUBDIVISION (If Applicable) /� / DIV ,� ELK LfOOT/ T
DIRECTIONS FOR LOCATING SITE Co re cr eT C. /��r s L a 11• �r '.,n 4 Pin e �T e P ✓ C-�'
�oz� Sketch loca 'o of property n this"space.
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H:1ON-SITRL!•:RRSVIETI.w Revlalon 01107196
PART 2: PURPOSE OF APPLICATION
2A. OPTION ONE
UI am applying for a bank loan and the bank has asked for an evaluation of the
following:
L ' Septic System (Fee: S62)
• Age of System
Age of House
• Nupber of Bedrooms ? ��j,na ✓'L /
• Name of Last Owner ifl,d.w (�h°���kA e
• Is house currently occupied?
• Attach ppaper's report, dated within lest 3 years, stating whether the system was pumped, the size and
condition of the tank, and the condition of the baffles.
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L_I water System (Fee: $62)
• Number of service corrections on water system
If public water system:
errs ot system
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LJ Both.(Fee: $100)
• Provide information shown above for both septic and water systems
2B. OPTION TWO
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t_1 I am applying for a building permit, and environmental health has required an
evaluation of the following:
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L.J Existing Septic System (Fee: $62)
• Age of System
• Nupber of Bedrooms
• Name of Last Owner
• Is house currently occupied?
• Attach pusper's report, dated within last 3 years, stating whether the system was pupped, 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 originat septic permit cannot be located and system more than 5 years old, submit signed as-built
drawing from certified designer or professional engineer.
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U Reserve Area for Future System Repair (Fee: $62)
• Two property excavated pits are 4 ft deep must be ready for inspection by the departaent. _
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L 1 Both (Fee: $62)
• Provide information shown above for both septic system and reserve area
2C. OPTION THREE
I am interested in knowing in general terms the suitability of a parcel for septic
system placement. (Fee: $62 base, plus $45/hour after first hour)
Describe the intended use of the property and the reason for requesting the review:
H:IeH-SITS\6HRSVrbw.w Revlaloa 01107196
PART 3: PLOT PLAN
Use this space to draw a detailed plot plan, or attach one to this application. A detailed plot plan is one 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.
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PART 4: AUTHORIZATION
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APPLICANT � �� /"/ 5 DATE
w:10N-SITSISRRZVI6tr.w Revision 01/07/96
PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY
SA. DETERMINATION OF APPLICABLE STANDARDS
The primary drainfield area must meet the following standards:
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LJ Meet current standards LJ Standard marine system
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T�xo overt failure LJ Not applicable.
The reserve drainfield area must have site characteristics that could support a septic system that would meet the
following standards:
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LJ Meet current standards. LJ Meet marine repair standards.
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LJ Meet marine expansion standards. of applicable.
5B. WATER SYSTEM
YES NO INDIVIDUAL WATER SYSTEM
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LJ U A waterXe
e was taken by health department staff and analyzed. Total coliform bacteria were
determibe absent. Laboratory results are attached to-this report.
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LJ LJ The welNat inspected. The sanitary seal a ars satisfactory.
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LJ LJ The welg was i petted. The casi projected above ground and ground was sloped away from the
casing.
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LJ U The welwas inspected. septic systems, chemical storage facilities, manure piles, animal feed
lots, o obvious sour o contamination were located within a 100 foot radius of the well.
PUBLIC WATER YSTEMLJ LJ Recordste w6er sampling requir is are being satisfied.
r-I nLJ LJ Recordste the Water Facility Invento orm is current.
n nLJ LJ Departmees contain no information indicati the system is out of compliance with state or local
water squirements.
5C. SEPTIC SYSTEM
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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.
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LJ Records for this property contain a septic permit, design (if required), final inspection approval, and
as-built approval.
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LJ The drainfield site was inspected, and appears consistent with recorded documents.
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LJ The drainfield area appears to be maintained in an acceptable manner.
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U The drainfield area (the area where the drai of field is assumed to be located based on office records
and/or observed site conditonu) appears to be maintained in an acceptable manner.
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Y� LJ The drainfield area (the area where the drainfield is assumed to be located based on office records
and/or observed site conditins) show no indication of overt failure at the time of inspection.
N:10N-SI7EIENRE TEW.w Revjsjon 01/07196
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:
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l-- The system appeared to be functioning adequately at the time of inspection and
and meets current design standards.
The system appeared to be functioning adequately at the time of inspection.
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U 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:
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tJ Current standards.
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tJ Marine expansion standards.
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Marine repair standards, Treatment Standard
Not applicable.
Comments:
6C. WATER SYSTEM
The water sy em was evaluated?oan
the following determination has been made:
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u The water s cX individual well that appears to be a
satisfactory sater for a single family residence. The water
was sampled, aneria were found to be absent.
The water sourcater system that appears to be in substantial
compliance withulations.
Comments:
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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.
Resource land and critical area checklist may be required by Department of Community Development prior to issuance of
developmental permit.
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INSPECTOR DATE
H:%0N-SITEIEHREVIEw.W Revision 01/07/96