HomeMy WebLinkAboutLRG Application - 8/9/2023 MASON COUNTY
�' `'c 415 N 61H STREET,SHELTON WA 98584
1%�� �.. ,.,��
I l .,5- SHELTON:360 427-9670,EXT.400
� COMMUNITY SERVICES BELFAIR:360-275-4467,EXT.400
ELMA:360-482-5269,EXT.400
FAX:360-427-7798
�L"N.•FI17�i,, V. Building,Planning,Environmental Health,Community Health i
\J'
....,_.._ :.....�.�.�..._._____...__`__. _...__ -n— •- —cam z.�.—.=_v
APPLICATION FOR LAND USE EVALUATION I
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.
Y 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.
PART 1 : APPLICANT/PARCEL IDENTIFICATION
Lid' Large Lot Subdivision ❑ Subdivision
0 Short Subdivision ❑ BLA
Name of Applicant N N 6C-efY\ eo SAACt1ph \hc• - Phone 3 O. 7Lf • 031{S
Mailing Address of Applicant 20I N,-1-1-Awt\\toi 1D-A
City Q)(10/0 t1S State WF\ Zip %932_
12-digit Tax Parcel No. .ZZ I-7 2-149 O030 / 121-12-LH bo`� c�
Property Legal Description Rkk At A(h PA
Lot Sizes (Acres or Square Feet 5 0? 5.2 3.6 7
LOT 1 LOT 2 LOT 3 LOT 4 LOT 5
Directions to Site -IAVkAi 1'lo•c }i1-\ Dh S1 y,2'�j, • V�-m �Q-'� OY,"�O '�omizs ad
"O q foWoltG15 DO -tinCl-, 49_4i
PART 2: INTENDED USE OF PARCEL
Intended Use of Property(Check One):
V Single Family Residence 0 Multi-Family Residence 0 Other,Specify
Water Source for Parcels(Check One):
V Individual Wells 0 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
iirrrrow
1
PART 3: HEALTH DEPARTMENT REVIEW (official use only)
Soil Logs and Site Characteristics ,
Test Pit A Test Pit A /
k- Lot# Lot#
Lot# �i
t# - Test Pit A Test Pit A
Te
Li �-- O -2- I LS CnZNL___ I
t - 2. li-t, '4--e`-,1 4-- I
Depth of Mottling Depth of Mottling
Depth of Mottling Depth of Mottling De P
Depth to Rest. Layer Depth to Rest. Layer Depth to Rest. Layer Depth to Rest. Layer
e
Soil Type (USDA) Soil Type (USDA) Soil Type (USDA)) Soil Type(USDA)
Test Pit B Test Pit B
Test Pit B Test Pit B
P
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
e
Soil Type (USDA) Soil Type (USDA) Soil Type (USDA) Soil Type (USDA)
Drain Curtain Drain
Curtain Drain Curtain Drain Curtain � Needed?
Needed?
Needed? Needed?
Slope /o
o Slope % Slope% Slope
Shoreline? (YIN)
Shoreline? (YIN) Shoreline? (Y/N) Shoreline? (Y/N)
Minimum Lot Size* Minimum Lot Size* Minimum Lot Size*
Minimum Lot Size*
—"— Revised 3/2/2017
This form may be scanned and available for public view on the Mason County Web site.
I
1.
i
*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 pc I'li v� '-e all$ �v u ,�,iL b U 5 ��r5 Ctua I4cii,
/ �/ r �
PART 4: REVIEW SUMMARY
171-.
MEETS HEALTH CODE
DOES NOT MEET HEALTH CODE
n
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):
I I 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:
I I Condition (s) required prior to approval have been met by the applicant
Health Official Date
PART 5: R• ' = E- SIGNATURE
. /d (..//i GAL"Q....j c?'_ Ci ,..- ___----/,
OY Health Official Date
This form may be scanned and available for public view on the Mason County Web site.
Revised 3/2/2017
1 I
pzN R °,v +oy ... = -.Ih Z 3
r-32W OF 4 It"
'a �'g ` l(jCU C9 Z y N �� Cl) U Z
Z 2Z 9Y W r 1 Hli6
Z _oWo3N 6 - I- , ' m j.W 49 , F Q zZzwozd u=o > 3 V o 3 °\ ;W K i p :9P� 3 ¢ O gg m S. t4r >> % f3UPWz. .og � m u k'Yrr*'` C iZrg = 3g. W ¢ W
m n ¢ si a $� � � ....._..___�._•' V 88 W y Z �o co OZ =o� .v
gE o� o so 0- s U I ° N d- y g � u O 5 - E—Wpz -Y..0z
~O Q pt22„° ¢ m VE 3 b ti ? 1 ice CC>6.i R 'Q Q /0,gt �' O w oNv•-,-
2 11115 $I O LL= 8 CC p O '6 `r 8 t - azza
yg� m z
W ¢'$g?' i U fa ° g O O 1 ° ¢ �>�\ T wT 3 2 ❑ m g X . W K W=tpQ
0 ,,°02Ni °� W z g g O ¢ z I o •V L-E F�O W 3 h 0 1 N~.�-�
a 8'34Iti, ]� p (1 ¢ W Q o = ¢ �Qi O im n 0 o gv d o
No<FM uC Y p p I i x pp y °'°'o O a o11 < wpwp Q U
N g!L §gi g; 8 f
g gg to 1 I r; 888 =
Z� 5892a, 97 p 1a n13 $ Y ti
li W .i g° h z i < Sgsy oi!� E E ` O
N W POOhIlIhIL
pFU 11th1g
3go yo g ? 1111
f Pll a I
m ` N ` •�(� < HP l'iI' �S — 5 I.
! 1�1,1gl I s3 °
s „c g- 8„B 14 of :E .
o_ n o�� ;4 s;E' 3 !ifl
1� 1 I its 8s N ow8 Z n`a9��(EEa% F • ¢ wS w�
at
os
aI. n
Q Z
7::\
0 0
J /
k ryz�" iBj( 6aN
A o o.s arim
�e a ;ctoLn dQy gB ` ' 'R
bL'
R: 3 -
w Rrvm
Ni a co
�$g lk J r
N Ri �? i
(f t E,r m ;F{jp9npp'°
Ill A
V �_, Q 6 =osog
r 4— ---
-,1,- '\ 0 8 i d oi 'uu0OS
s ,r. W n. 8 -E- 3
z
Q U
3 6 J a
0l�5 z
3 ., h
.^3 mto W '6 P'2 h g 4! <o
".. of > F� °
Hc'E
,.4e„E'. � .Yi� 3y4wy �¢u W J�= qg
w� n$WWN� °Nji 3 V q
um
n ,i�<tlaaas a! W3° �t u'w¢ C W $¢
aoon ,C ' d4NN(D ui cfri F.3 `N .0 6. Nam` 5,�'
y � ` �-5,4gi ii4 Z5�RN -�pa Q 2 UuAW
f .06"; �1 y6t�1N�NN$R�NNO Nynm µuWlo �i 9�rpl11II ,23pS Q 2G Ot7w
� paYi Z oUU°t t...2t.VO Q7aZ <=S N� Z ea n<
- g{�oz3 NN{ty a Wws )->.5 pp T�.��, VA / roc,'
lat U lf7j°1� C 13333g1-333W W o dSN 2 0. '44N Y.vp
353 W{a, JJJ� ��.pi,K >¢ U ¢ W O. S
iiiN`CUM �v°ii°o¢w q 7 4 j i5i 5N4
» � N �� pyU �� UO �11sEE� OZ
-.vn.----- Nhill C �8 W uoa� 'ua3