HomeMy WebLinkAboutSPL Application - 10/12/2023 MASON COUNTY 415 N 6n'STREET,SHELTON WA 98584
SHELTON:360-427-9670,EXT.400
COMMUNITY SERVICES BELFAIR:360-275-4467.EXT.400
ELMA:360-482-5269,EXT.400
eulldn4P6nnisasn*—n AHWMr n—eryH-10, FAX:360-427-7798
APPLICATION FOR LAND USE EVALUATION
Amoont Paid:
RcceiptNumber:
Instructions
1. An application is considered complete when the fee is paid and the fallowing 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.Property excavated pits are 5-feet deep
with a 4-foot deep sheg 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 Heakh On-Ske Standards)
➢ A scaled plat 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 airy existing or proposed wells,roads,or buildings within 100-feet of the property
boundaries.
2. After a completed application is received,gaff will inspect he property and provide the applicant with a written report.
Important in order to avoid additional costs,be sure the test holes andporceh are all)beped and Beady delineoted ai to lot and test
hole number.The identified test hobs most match the bMlons shown on Me proposedplot map.
PART 1 : APPLICANT/PARCEL IDENTIFICATION
❑ Large Lot Subdivision ❑ Subdivision
El Short Subdivision ❑ BLA
Name of ApplicantMichael Kibler Phone 360-561-2106
Mailing Address of Applicant 6959 Bailey Street
City Olympia State WA Zip 98513
12-digit Tax Parcel No. 32023-31-00102
Property Legal Description
Lot Sizes (Acres or Square Feet 1.34 1.34
LOT1 LOT2 LOT3 7T4 LOTS
Directions to Site:
RESULTANT LOT 1 OF BOUNDARY LINE ADJUSTMENT NO. 94-14 RECORDED MARCH
PART 2: INTENDED USE OF PARCEL
Intended Use of Property(Check One):
ED Single Family Residence O Multi-Family Residence O Other,Specify
Water Source for Parcels(Check One):
[71 Individual Wells O Community Well(Public Water System)
This form may be scanned and available for public New on Me Mason County Web site. Revised 3220I"7
'Minimum lot size applies to new subdivisions and is defined as the minimum all land area per
residence or residential equivalent(450 gall( r day).
COMMENTS 2 `� '' \
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PART 4: REVIEW SUMMARY
IXI 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(a):
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 (a)required prior to approval have been met by the applicant
Health Official Dale
PART ER SIG ATURE
W4 I_0
t' O Icial Date
This for mae Iy be scanned and available for public view on the Mason County Web site.
J:\EH PorinstONSITE FORMS\Current MISC.PoMQ017 Land Use Evaluation Appllca0an.doa Updated:12/23/2016 1:32:00 PM
Revised 12/30/2016
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