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Home My WebLink AboutSPL2016-00005 - SPL Application - 7/7/2016 MASON COUNTY PUBLIC HEALTH - PO BOX 1666 SHELTON,WA 98584 (360) TON APPLICATION FOR LAND USE EVALUATION SHELFAX (360)427-W20 Receipt Number 57-201(0--(p SO Date of Payment '7 7�Z01(0 ELMA (360)482-5269 INSTRUCTIONS BELFAIR (360)275-4467 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 Environmental Health Document"Procedures for Obtaining On-Site Sewage Disposal Permit"for more specific directions) ➢ 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 FLAGGED 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 �( Short Subdivision Subdivision 1:1BLA $310+$21 per acre JR $310 $517+$31 per parcel $103 office review NAME OF APPLICANT lReI7/17s(111W �Ps�� L� C TELEPHONE( MAILING ADDRESS PO $O)< 6 4 0 3e%�a�r W,4 995;? 9 City State, Zip ASSESSOR'S PARCEL NUMBER PROPERTY LEGAL DESCRIPTION LOT SIZES(ACRES OR SQUARE FEETI� 10,6 Z 46,9 3 5.84- Lot 1 Lot 2 Lot 3 Lot 4 D C IONS FOR LOCA ING SITE e.Sf T PART 2: INTENDED USE OF PARCEL INTENDED USE OF PROPERTY(CHECK ONE): 0 Single Family Residences Multi-Family Residence ❑Other,specify: WATER SOURCE FOR PARCELS(CHECK ONE): Individual Wells 'R Community Well(Public Water System) This form may be scanned and available for public view on the Mason County Web site. Part 3: Health Department Review (Official Use Only) Soil Logs and Site Characteristics Lot# A Lot# Lot# Lot# Test Pit A Test Pit A Test Pit A Test Pit A 0 -2-70 t_V S l-F 30 -coo Gw`5 ZO - c,90 C�w•s 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 AJA NA OVA PA" Soil Type (USDA) Soil Type (USDA) Soil Type (USDA) Soil Type (U`�SDA) Test Pit B Test Pit B Test Pit B Test Pit B JJ A�- /VA Depth of ottling Depth of ottling /MoftlingDepth Mottling Depth oRest. Layer Depth Rest. Layer Dept to Rest. Layer Soil ype (USDA) Soil pe (USDA) Soi Type (USDA) Curtain Drain Curtain Drain Curtain Drain Curtain Drain Needed?AID Needed?_,& Q Needed?p1D Needed? .)O Slope % Slope % Slope % Slope % -S �o 0 -t5 �J-S Shoreline? (Y/N) S�line? (Y/N) Shoreline? (Y/N) Shoreline? �line? (Y/N) Minimum Lot Size* Minimum Lot Size* Minimum Lot Size* Minimum Lot Size* 000 000 1 1-113',000 1 S"r000 - 16 coo, 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 7 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 RE R7:7 3JZZ ) 1-7 Health Official Date I This form may be scanned and available for public view on the Mason County Web site. 0 i 0 ~ S0128,011W 260198' A m I� a 1301.99' 711.00' —— 590.99' -+ O rp9 $ 2a 20 a 7T� s$ v r� b P v it I 1C 3 S $p3 H 3 b gg;4 1q )'soos9,4e w na24' o R I 0 Vx ni � 3 'I b5� 14 �nl a 50081'10'W 58a 79' 351.49' ZI 1-21 lb S� N z TV NO"�T�' / 2 N0074'10'f _ AISZ,:xl.__ Y I I a•� ; � � Im �� N3°°3 xO too 2��Y ..oJ I � •�. 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