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Home My WebLink AboutLand Use Evaluation - SPL Application r.WN CotrNv PublicHealth AAreys worWrq far a healthier MasonCauMy 415 N 61h Street,Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext 400 Belfair:(360)275-4467 ext 400 ❖ Elma:(360)482-5269 ext 400 FAX(360)427-7787 APPLICATION FOR LAND USE EVALUATION Amount Paid: Receipt Number: Instructions 1. An application is considered complete when the fee is paid and the following elements have been addressed: ➢ Parts 1 and 2 of the application form must be completed. ➢ One properly excavated test-hole per proposed parcel must be ready for inspection.Properly excavated pits are 5-feet deep with a 4-foot deep shelf on one end of pit.The 4-foot deep shelf must slope up to the ground surface for easy ingress and egress.(See the Mason County Public Health On-Site Standards) ill'I ➢ A scaled plot plan must be attached to the application.The scaled plot plan must show the precise location of the test holes, dimensions of the property and locations of any existing or proposed wells,roads,or buildings within 100-feet of the property boundaries. 2. After a completed application is received,staff will inspect the property and provide the applicant with a written report. Important:in order to avoid additional costs,be sure the test holes and parcels are all}lagged and clearly delineated as to lot and test hole number.The identified test holes must match the locations shown on the proposed plot map. PART 1. Applicant/Parcel Identification Large Lot Subdivision$360 +$35 per acre ❑ Subdivision $530 + $35 per parcel Short Subdivision $360 , ` ❑r BLA $120 office review A-Name of Applicant �t, �� - -tC Phone Mailing Address of Applicant N r, -ory t x F-h t t_ p City Mf�Arl L .6,d State W Ar Zip g x S29 12-digit Tax Parcel No. It 2- 3-32 — SO — !!�ooY Property Legal Description t� Lot Sizes (Acres or Square Feet) 7, SS16 9 7, 9'I t Lot 1 Lot 2 Lot 3 Lot 4 Directions to Site Part 2: Intended Use of Parcel Intended Use Of Property(Check One): ❑ Single Family Residence ❑ Multi-Family Residence Other, Specify Water Source for Parcels (Check One): ❑ Individual Wells jef—Community Well (Public Water System) This form may be scanned and available for public view on the Mason County Web site. J:\EH Forms\Land Use Evaluation Application.doc Updated:12/7/2015 9:11:00 AM Revised 12/7/2015 I Part 3: Health Department Review (Official Use Only) Soil Logs and Site Characteristics Lot# Lot# Lot# Lot# Test Pit A Test Pit A Test Pit A Test Pit A l � > Depth of Mottling Depth of Mottling Depth of Mottling Depth of Mottling Depth to Rest. Layer Depth to Rest. Layer Depth to Rest. Layer Depth to Rest. Layer Soil Type (USDA) Soil Type (USDA) Soil Type (USDA) Soil Type (USDA) Test Pit B Test Pit B Test Pit B Test Pit B a Depth of Mottling Depth of Mottling Depth of Mottling Depth of Mottling Depth to Rest. Layer Depth to Rest. Layer Depth to Rest. Layer Depth to Rest. Layer Soil Type (USDA) Soil Type (USDA) Soil Type (USDA) Soil Type (USDA) Curtain Drain Curtain Drain Curtain Drain Curtain Drain Needed?_ Needed?_ Needed?_ Needed?_ Slope % Slope % Slope % Slope % s Shoreline? (Y/N) Shoreline? (Y/N) Shoreline? (Y/N) Shoreline? (Y/N) Minimum Lot Size* Minimum Lot Size* Minimum Lot Size* Minimum Lot Size* This form may be scanned and available for public view on the Mason County Web site. 7:\EH Forms\Land Use Evaluation Application.doc Updated:12/7/2015 9:11:00 AM Revised 12/7/2015 *Minimum lot size applies to new subdivisions and is defined as the minimum allowable land area per residence or residential equivalent (450 gallons per day). COMMENTS The lots, parcels or tracts contained within this land segregation have been created without _ — establishing a potable water supply. No building permit necessitating potable water will be issued _ without first satisfying potable water requirements as required by the Mason County Health Services Director. — o ..ter --..n no-t-,o... �' o%12-' r jt% as �r t,o-r PART 4: REVIEW SUMMARY MEETS HEALTH CODE DOES NOT MEET HEALTH CODE After examining lot size, proposed water source and soil type, it is the determination of Mason County Public Health that each proposed parcel cannot support an on-site sewage disposal system meeting the requirements of state and local regulations. This determination is based on consideration of the following factor(s): HOLD APPROVAL UNTIL FURTHER ACTIONS ARE TAKEN BY APPLICANT After examining lot size, proposed water source and soil type, it is the determination of Mason County Public Health that each proposed parcel cannot support an on-site sewage disposal system meeting the requirements of state and local regulations until the following conditions are met: Condition (s) required prior to approval have been met by the applicant Health Official Date PART 5 REVIEWXR SIGNATURE q i3 ► co Health Official ate This form may be scanned and available for public view on the Mason County Web site. J:\EH Fors\land Use Evaluation Application.doc Updated:12/7/2015 9:11:00 AM Revised 12/7/2015 V • I ► pD Z vs A C 04. low p Arlv IJ vex � a I IN d r 3 i 5� °i, � ¢ to cooO j j Q O N O to C4 i OV co r^ II I nL r a.nLU 00 "'� n.. Q 4 4k� ; I �O err N I ri LP' v!j 1 H I I x W 1� In i