HomeMy WebLinkAboutSPL2023-00003 - SPL Application ii
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MASON COUNTY 415 N 6TH STREET, SHELTON WA 98584
SHELTON:360 427-9670, EXT.400
f`` 1 7 `ti? COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
ELMA: 360 482 5269, EXT.400
%,�` Y Building,Planning,Environmental Health,Community Health FAX:360-427-7798
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:
Y 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)
➢ 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.
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PART 1 : APPLICANT/PARCEL IDENTIFICATION
❑ Large Lot Subdivision 0 Subdivision
O Short Subdivision ❑ BLA
Name of ApplicantDudley and Barbara Cooney Phone (360) 427-7876
Mailing Address of Applicant 3590 E Pickering Road
City Shelton State Wa• Zip 98584
12-digit Tax Parcel No. 22004-41-00090
Property Legal Description Gov't Lot 1 (NE 1/4 SE 1/4) Sec. 4, T2ON, R2W, W.M.
5,D 1
Lot Sizes (Acres or Square Feet 3.03 Acres 6799 Acres
LOT 1 LOT 2 LOT 3 LOT 4 LOT 5
Directions to Site:
PART 2: INTENDED USE OF PARCEL
Intended Use of Property(Check One):
0 Single Family Residence 0 Multi-Family Residence CI Other,Specify
Commercial Lot 1
Water Source for Parcels(Check One):
El Individual Wells Cl Community Well(Public Water System)
This form may be scanned and available for public view on the Mason County Web site. Revised 3/2/2017
*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
Both Proposed lots are Fully Developed. There is and existing Class B well. It is Pickering Water Co
PART 4: REVIEW SUMMARY
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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):
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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) r qui ed prior to approval have been met by the applicant
I Official Date
PART 5: REV(It k SIGNATURE
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Health Official Date
This form may be scanned and available for public view on the Mason County Web site. Revised 3/2/2017