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HomeMy WebLinkAboutCRT2023-00004 - CRT Application - 5/22/2023 MASON COUNTY 415 N 6TH STREET,SHELTON WA 98584 SHELTON: 360-427-9670, EXT.400 Public Health & Human Services BELFAIR: 360-275-4467, EXT.400 ELMA: 360-482-5269, EXT.400 FAX: 360-427-7798 � 0 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW -I MAY 2 2 202 Permit Number Payment Information Type of Review 1� Septic and Water $430 CRT Receipt Numbei Septic $255 a?J _ Cash Water $255 (Individual and Two Party) OCCC4 Check Date of Payment e` J 1 Group B WS $95.00 (+$95.00/hour beyond 1 hour) Property Evaluation $350 • • //// Resample $30 lab fee Instructions: Complete Parts 1. 2, and 3 completely and accurately. With the application form, please submit the appropriate fee and the necessary documents such as a septic system maintenance report. If the application is for a property evaluation for septic, be sure the test holes have been dug and the location is clearly marked at the site. PART 1. APPLICANT AND PARCEL IDENTIFICATION Name of Applicant LO.C2x\ SAA1er,ekewA-0-,Jud, i4oey-tt Esbaie-Phone (3(ve)—.t0435 33 Mailing Address of Applicant 1(133 NW Circle. t'r. ?kr#VL City Y6'J'sbs,, State 1,0 A- Zip q$3'1 d 12-digit Tax Parcel No. 2ZZ3 - S 1 0(o 00r\ Site Address Brief Legal Description Trails E_Aci' N 2- Z.1K to L-c"T Driving Directions Lok IS ©ly•rp)s L 'r;rt. r Tra;ls EAck Lk. 4 � Cu+ 1wl Le1 o - Page 1 of 4 This form may be scanned and available for public view on the Mason County Web site. Revised 12/8/2022 PART 2: TYPE OF REVIEW Septic System • Age of system • Age of house • Number of bedrooms • Name of last owner • Is house currently occupied? YES NO • If not occupied, how long has it been vacant? . Water System • Number of service connections on the water system? • If a public water system, name of system • WFI number V' Property Evaluation (soil logs) Property evaluations provide, in general terms, the suitability for a parcel for septic system placement. THIS DOES NOT GUARANTEE FUTURE SEPTIC SYSTEM APPROVAL. • Describe the intended use of the property and the reason for requesting the review. s -4c Stele. , in\-e.n&eck r use as a- s;� re a.�,1. home PART 3: PLOT PLAN Use the space below to draw a detailed plot plan, or attach a detailed plot plan to this application. The plot plan should include the following: North Arrow, Location of Test Holes, Location of Existing Septic System. Dimensions of Property, Location of any Drinking Water Sources(wells. springs, etc.) Roads, Easements, Surface Water, and Buildings on the property. (skip Part 3 for Group B water system review) LOT SIZE S C e Acres COMPASS Applicant's Signature: U 1, - L----- Date 44 (4,I Page 2 of 4 This form may be scanned and available for public view on the Mason County Web site. Revised 12/8/2022 PART 4: HEALTH DEPARTMENT FINDINGS — OFFICIAL USE ONLY Septic System Yes No The septic system was inspected by an appropriate maintenance provider and the submitted report ❑ ❑ is current. ❑ ❑ Records for this property contain a septic permit, design,final approval and as as-built drawing. ❑ ❑ The site was inspected and the system location appears to be consistent with recorded documents. ❑ ❑ The area of the on-site system appears to be maintained in an acceptable manner. ❑ ❑ Was Operation and Maintenance a condition of permit approval? ❑ r Is a copy of a current Operation and Maintenance report attached? Water System Yes No Individual Water System A water sample was taken by Public Health staff.Total coliform bacteria were determined to be ❑ C absent. Laboratory results are attached to this report. ❑ C The well cap was inspected. The sanitary seal appears satisfactory. The well casing was inspected. The casing projected above ground and the ground sloped away ❑ C from the casing. The well site was inspected. No septic systems, chemical storage facilities, manure pile, animal ❑ G feedlots or other obvious sources of contamination appeared within a 100-foot radius of the well. Yes No Public Water System ❑ ❑ Records indicate water-sampling requirements are being satisfied. ❑ CI Records indicate the Water Facility Inventory form is current. ❑ C Department files contain water system design and letter of approval. Soil Conditions Test Hole #1 Test Hole #2 Test Hole #3 0 2,1 r u�rnn 3 i C C 11 Soil Type: L v�� Soil Type: J �- / Soil Type: Restrictive layer: '22 ` t erk Restrictive layer:_`L1 Restrictive layer: Slope: CI 0It Slope: 5-`1 0 L Slope: Distance to Shoreline: \ o'y- Distance to Shoreline: 10 Distance to Shoreline: Page 3 of 4 This form may be scanned and available for public view on the Mason County Web site. Rev iscd 12/8/2022 d • PART 5: HEALTH DEPARTMENT OBSERVATIONS - FOR OFFICIAL USE ONLY Primary Drainfield Yes No The system appears to be functioning adequately at the time of the inspection. (Only applicable if L Li system has been in use on a regular basis for the last 6 months.) ❑ ❑ Sanitary survey? Pass Fail H Suspect . I Not applicable Water System Yes No The water source consists of an individual(or a two-party)well that appears to be a satisfactory source of potable water for a single-family(or two single family) residence(s). The water was I sampled and coliform bacteria were absent. The water source is a public water system that appears to be in compliance with applicable U regulations. n Well Construction Permit Pass . Fail PART 6: Comments (?Lm S - i1 vtti 41 I y ( O k iyY y vhe6(1,f41 S arLA grAikeAlx c * lOarn Mu vYt o*1 �.r M -t ) ,1'b�t ca 4�� Se-a-5ur .J vac{-w bk. Inspector T V) Date Co I ( I t 'iD Important Notice: Findings&determinations of this review reflect observed conditions as they exist on the day the evaluation was performed.Absolutely no claim is made by this office, expressed or implied concerning the future success, failure or permit approval of the system and site evaluated. Page 4 of 4 This form may be scanned and available for public view on the Mason County Web site. Revised 12/8/2022 • v130 / h 22223-51-06027 5106027 i) ti 0 Sj�sj�0s 22223-51-06009 ti49 oi <a O o 6 �k� s s �s 5106009 i( 2 ?s tiY30 �h c Z by 001.0 v. 'ti 00 2 2223-51-06025 tD 0 cA �00 5106025 0 .� 47�b O <1 in i0 P '�„��'yo L j c' ( °V h , 6 N IN o N rZ3a ti 06024 ~84 ,-,- ti� 6 m 24 r, 0 o 22223-51-06007 2 i) 22223-51-06011 D 5106007 5106011 2 iY 0 ^r135 w 0 / > U f a Z n 22223-51-06012 in -- 2 5106012 N 0 22223-51-06006 iNI 5106006 2 -A "13 5 N 2 "131 1 ParcellD: 22223-51-06009 nik , Belfair WA 98528 LAND TITI.F.COMPANY- This map/plat is being furnished as an aid in locating the herein described land in rr•or••+rv•ni•r•aanmrrr•r 9657 Levin Rd NW,5uite100•S11verdale,WA98383 relation to adjoining streets, natural boundaries and other land, and is not a survey Ptonr.360692.2233or800.950.4321 ax:360.692_2244 of the land depicted. Except to the extent a policy of title insurance is expressly modified by endorsement, if any, the company does not insure dimensions, distances, location of easements, acreage or other matters shown thereon.