HomeMy WebLinkAboutBLD Water Adequacy - 6/4/1997 MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SHELTON, WA 98584
(206) 427-9670
FAX 427-7798
APPLICATION FOR ENVIRONMENTAL HEALTH REVIE(((W�w���
Receipt No:
Date of Payment: 'UnIJ� LL77 W /� { L�IfL�L777
Septic Review: ,JUN O 4 IJJ,
Water Review:
Property Evaluation: HEALTH
SERVICES
ERV,ICEJ
INSTRUCTIONS
1. An application is considered complete when the fee is paid, Parts 1-4 of the application farm are completed.
(assistance will be provided upon request for completing Part Two), the necessary paperrork'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 project requires the excavation of more than 3 test holes, the department may charge the applicant an
hourly rate of $37/hour as set forth by the Mason County Board of Health.
PART 1_ APPLICANT/PARCEL IDENTIFICATION
:::::::::::::::::::::::::::::::::::::::::::........ .. A' Q u A
NAME OF APPLICANT DFIRI-F,NE NOkL-IIJ TELEPHONE (mO&) z< - —0$7
SITE/HOUSE ADDRESS /by 7g WOOTEN LAKE
MAILING ADDRESS 3,?g / N C2O_Y w
TAc.oMA A /D�
ACREAGE
e�_te yin
ASSESSOR'S PARCEL NUMBER 21— - O
LEGAL PROPERTY DESCRIPTION
SUBDIVISION (If Applicable) DIV HLK LOT
DIRECTIONS FOR LOCATING SITE E}�'TAC N�.Q H A P
Sketch location of property in this space.
`Lid.n
La12c , SEE Pala
`]a. si • Aevised 12/28/93
PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY
............................... ............................. .................
..................... ........ .................................
.............................
5A. DETERMINATION OF APPLICABLE STANDARDS
• The p i drainfield area must met the following standards:
5�—t current standards El Standard marine system
11 No overt failure [I Not applicable.
The reserve drainfield area must have site characteristics that could support a septic system that would met the
foll%standards: 11
meet current standards. Meet marine repair standards.
F1Meet marine expansion standards. El Not applicable.
5B. WATER SYSTEM
YES NO INDIVIDUAL WATER SYSTEM
ElA water a Is was taken by health department staff and analyzed. Total coliform bacteria were
11 =determined role W absent. Laboratory results are attached to this report.
El11 The well cap was inspected. The sanitary seal appears satisfactory.
DEl The well casing was inspected The casing projected abov round and ground was sloped away from the
casing.
The well Site was inspected. No septic a, chemical storage facilities, manure piles, animal feed
lots, or other obvious sources of cant nation were located within a 100 fact radius of the well.
In a
The
The
a
The
iota,
a
we w ca
sing.
0 g
0 1 r
c casing p Si
Bite
W n other a g was
wa
s
i
III n a
ins
pected,P
so te sources
t d
asp
c t
ca
sing
a
c
i J ng
projected c
he-a satisfactory.
chemical t
th rces 0 Cant na re t
Th ad ad
"a I r storage rag
d Is a
f
n
a
d_i gr
ound i
i f Jac. d within a 10
ATER SYSTEM
PUBLIC SYSTEM
V
Records indicate Wat sampling requirements are being sat ied.
ERea ry
l Records ind to the Water Facility Inventory fare is current.
in in ti
De nt files contain no information indicating the system is out of compliance with state or local
ter system requirements.
5C. SEPTIC SYSTEM
YES NO
0 El The
septic
eptic nk was inspected by a certified septic tank pumper within the past 2 years and found to be
in satisfactory ndition. A pumper Is evaluation is attached to this report.
El11 Records for this property main a septic permit, design (Jf,required), final inspection approval, and
as-built approval.
11 0 The drainfield site was inspected, and re consistent With recorded documents.
0 nt in a a ic permit,
design_(i f Xeq'
property
septic
t
Y
was
inspected,
and r. consistent With re'll El The drainfield area appears to maintained in n acceptable manner.
11 0 The drainfield area VK"s area where the drainfield is L umed to be located based on office records
a
conditons) appears to be maintained in acceptable manner.
and/or observed
a a
11 El The drain Id area (the area where the drainfield is assumed to be located based on office records
and/.,Vob..r'.d site conditons) show no indication of overt failure at the time of inspection.
No. Si . Revised 12/28/93
5D. SOIL CONDITIONS
TEST HOLE #1 TEST HOLE #2 TEST HOLE #3
O `H" NN✓t�� l d 4��7
C)j S4^d( Goq�
-old
exML15
S-40-i
Depth of root pen. : Depth of root pen. : Depth of root pen. : _
Depth to restr. layer Depth to restr. layerLiS Depth to restr. layer
Soil Type: Soil Type: 3 Soil Type:
Vertical Separation:" Vertical Separation:" o�l Vertical Separation:'
p VlA Ln Curtain drainable? (Y/N/NA) : ( o,
ko `a Slope
Shoreline? (Y/N) :
Minimum lot size:'
Designer level:
Vertical separation is the depth of unsaturated, original, undisturbed soil of Types 2-6 that exists between
the bottom of the subsurface absorption system and a restrictive layer or the watertable. Vertical separation
for purposes of designating designer level will be calculated by the health department based on a 12-inch deep
5E. OTHER NOTES AND COMMENTS
7}li yyAipaA stP✓u✓i�a �a d F+o �� e cke oh o �i�� �/l sr2�
LA;AA, b 1101M n-L dLAi\ rock U6,1 +'ns OWL
s1V% 3
2 vi Sa
o ' S u o't .
S r v
F F4 k+%'L
v
w.
k_aeyf6 WF� UA4(6, o�
2•.13
No. S1 • Revised 12/28/93