HomeMy WebLinkAboutLRG Application - 1/9/2023 MASON COUNTY 415 N 61"STREET, SHELTON WA 98584
SHELTON: 360-427-9670, EXT.400
COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
ELMA: 360-482-5269, EXT.400
Building,Planning,Environmental Health,Community Health
FAX: 360-427-7798.
APPLICATION FOR LAND USE EVALUATION /
Amount Paid: 61S JAN 09 2023
Receipt Number: •w AlaOr Str
eet
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)
4 > 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 0 Subdivision
0 Short Subdivision ;� 0 BLA (�
Name of Applicant � )Ot)J ICI M-Q .f�7-40 Ste, /-2f'1 s Phone U. SO I' 5 9 0q'
Mailing Address of Applicant {� O. box 2LoZZ-P
City E I f U State \►r Zip 9 S662 S
12-digit Tax Parcel No. ZZ 1E6- 2Z_ 00000 l
Property Legal Description NW N 23-21 -*Z
Lot Sizes (Acres or Square Feet 5 OI(XeS 591eks- 5&CY 50tc-Ye-s6 acres
LOT 1 LOT 2 LOT 3 LOT 4 LOT 5
Directions to Site Off 1-11m1 tU e. soutifu,ril Vi-ew
goad znfari CQ,.. I a a. >ari hi-- on Thema,s I a. Left
Dn ?-pri I by-ezno-e IDr1Vor r)x. 1J930'f Pic) Our paper--y is oatki rr9 :
PART 2: INTENDED USE OF PARCEL
Intended Use of Property (Check One):
Single Family Residence f 1 Multi-Family Residence 1 Other, Specify
Water Source for Parcels (Check One):
1 Individual Wells )Q(' 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
PART 3: HEALTH DEPARTMENT REVIEW (official use only)
Soil Logs and Site Characteristics
V
Lot# I Lot# -4' Lot# 3 Lot#
Test Pit A Test Pit A Test Pit A Test Pit A
0 , 3j_ 0 ',-0 5-L, 0 -3,
o 1
a/ Y --‘..7 — 5 7 ,.4')
( D AA?
Depth of Mottling Depth of Mottling Depth of Mottling Depth of Mottling
Depth to Rest. Layer Depth to Rest. Layer Depth o Rest. Layer Depth to Rest. Layer
Soil Type (USDA) Soil Type (USDA) Soil Tj/c (USDA) Soil Type (USDA)
Test Pita, c Test Pita L Test Pit 9 7 Test Pit i
' t.2--- 17
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 %
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. 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 4--e5 110 S GEC. f ./I/e�/ - ,, O
AD
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: RE7E-W R SIGNATURE
cy.,jA/ttoi -.23
ealth Official Date
This form may be scanned and available for public view on the Mason County Web site. Revised 3/2/2017
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