HomeMy WebLinkAboutSWG Onsite Survey - 6/20/1994 ® - ON-SITE SEWAGE SYSTEM SURVEY Q i`
LOWER HOOD CANAL CLEAN WATER DISTRICT
PROJECT: LHC AREA: _#4 RELFAIR DATE:
OWNER INFORMATION : TITLE: ,
FIItST N" AST NAME:
ADDRFS': Y16 R16PA1 s1y�tr►I IJ+�u c'ITY:� Pipk_ STATE:-!L)& ZIP:1850 J
OWNER'S PHONE: q`l�3 "5O4 I ' 0" ,'S PHONE: i 75-383 a
SITE INI19RMATION (Mark SAME if same as above) '$I—t�� �}
PARCEL# jeQ33a --- ----
occuP s %TITLh N1Ar� - t
FIRST NAME: -nm'60 ' " L 2n*LAST NAME:
r
ADD RR :� ���1J�A. „ CITY: e.� t' -STATE: h ZIP: -1 a 3 j
® N[1ME OF RESIDENTS: *ELL DEPTH
JMSID. E TYPE: .._ `( F -Full;Time Residence; S - Seasdttal Residence;
Recis gonal Residence; Cf- Commercial; I =Industrial; Multi-family Residence; V - Vacant)
ON-srrE CEWAGE SYSTEM TYPE: Amer all that apply. ( S - Standard tank and dminfield;
I3- Pressuve DistribuCori; F- b4an �il"tei; M -Mound; T - Deep.Ttl tch),H , Qut House; O - Other;
U - Unknown
INSTAthONDATE YEAR LAST PUMP : LA Enter Year or U- Unknown
`:GENERAL LOCATJON OF SYSTEM: F-Fret Yard; B - Back Yard; S - Side Yard;
A- Adjacent Lot; U-Unknown
'PERMISSION FOR�CCESS TO INS THE ON-snIE SYSTEM (Y/N)
-(NOTE.Mason County Health Code p es right of endy provisions. However, ourpollcy is to gain
permissio to access on-site systems.. Yo, TIRE
is�appreciated and saves valuable time and money
f®r�County. Applicable codes pe#aining to this matter will be provided for you upon request.)
SIGNATURE o rpkelv�1 eS' e. Eo k'.lpra ..?r DATE 6 �
SpeaA�is}
Comment$:
DO TOY WAIV"1"T°0'UZffVE INFORMATION ABOUT WATER CONSERVATION? (Y/N)
9
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JUG 2 0 1994
HEALTH SERVICES
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LOWER HOOD CANAL FIELD INSPECTION FORM
Initial Information:
Area: �t Added to database(Y/l):
Owner Name: Permission to Inspect ?:
Site Address: I Appointment Required ?:
Parcel#: 3 _ 3 V Appointment Date:
Occupant Name:
Inspections:
Level1: 0 Level IC: Level2:
Inspection Team: Jx. Updated database(Y/N): _
Inspection Results:
Distance between septic tank and surface water: OL d- (ft)
Distance between septic tank and well: Aft)
Distance between drainfield and surface water: (ft)
Distance between drainfield and well: (ft)
Occupancy(occupants/bedrooms): &U)+
Other(Larger on-site, business..etc... C&MW%'f<AgJ 461 out�
✓ The septic system appeared to be functioning at the time of the inspection; no obvious J
. problems were observed.
The drainfield area may be compromised due to vehicular traffic. (i.e.: parking, driving)
There are indications of poor system maintenance. (i.e.: lack of regular pumping, leaky
plumbing, slow drains, excessive chemical dumping, high water usage)
Construction was noted in the drainfield area.
Sewage was observed entering surface water; confirmed by visual dye and fecal coliform
count of>200fc/I00m1.
An unpermitted outhouse was observed.
Other:
Additional Comments:
System Classification:
Pass: Fail: Suspect:
Failure Priority:
Priorities
® 1: alnees injury related.2: Visual Dye,open or surfacing sewage entering surface water,out bouses a cuspoob with<3ft Vert.Sep,fre n
SHW.3: Surfumg seeping effluent not entering surface water.4:Other unacceptable installaGeus;intermittently failing systems not entering
surface water.5:Primarily aealhelics(odor)
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SITE DIAGRAM
1 h bra vt�
1 \'
a 1
DYE PACKET RESULTS
Site Back®vund Series t Relrieval Series 2 Retrieval Series 3 Retrieval
Number Date Date Recalls Date Date Resuts Date Date Results Date Date Results
Placed Retrieve Placed Retrieve Placed Retrieve Placed Retrieve
BACTERIOLOGICAL RESULTS
Site Date Results
Number