HomeMy WebLinkAboutCRT2004-00139 - CRT Loan Cert. / EH Review - 10/29/2004 MASON COUNTY RECEIV
DEPARTMENT OF HEALTH SERVICES OCT `) u
42
426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584 h
SHELTON (360)427-9670 ELMA (360)482-5269 BELFAIR (360 275-4467 SEATTLE (206)464-6968
WEB htm://www co mason wa us FAX (360)427-7798
APPLICATION FOR ENVIROMENTAL HEALTH REVIEW
PERMTI NUMBER PAYMENT INFORMATION TYPE OF REVIEW
❑ Septic and Water $150
CRT ReceipLNumb;�S ❑ Septic or Water $100
Property Evaluation $100+$50hr
0
11 Date of Payment [/ y ( ElResample $50 hr+lab fee 4-6 r
Important Notice: Findings&determinations of this review reflect observed conditions as they existed on the
day the evaluation was preformed. Absolutely no claim is made by this office,expressed or implied concerning
the firture success,failure or permit approval of the system and site evaluated.
*** FILL OUT APPLICATION COMPLETELY AND ACCURATELY ***
An application is considered complete when the fee is paid,parts 1, 2 and 3 of this application form are
completed,necessary paperwork is attached(i.e. pumpers report)and when required, soil evaluation holes have
been excavated.
PART 1: APPLICANT/PARCEL IDENTIFICATION J /
Name of Applicant R 2 t A AJ S✓� //VC/Say.Telephone 360— g77 ' 9(00
Mailing Address of Applicant -n U • �`St?,G i-1-1
-City asp t)A State 0 zip c 1,�Sg
12 Digit Tax Parcel No.
Brief Legal Description L+ 1 -L 1461,41
Driving Directions A/ 161 'Tp COI/ n Aa�1 L�,, Os-. U��IAI A�A
4, L4 fo `eaa/ Za
SKETCH LOCATION OF PROPERTY IN THIS SPACE
,22 Certification for Financial Institute or Property Transaction
El Septic System(Fee$100)
• Age of System
• Age of House
• Number of Bedrooms
• Name of Last Owner
• Is house currently occupied? Yes/No(circle one)
• Has house been occupied on a regular basis for the last 30 days? Yes/No(circle one)
Water System (Fee$100)
• Number of service connections on the water system
• If a public water system, name of system
• WFI Number
Both (Fee$150)-Fill out the above for septic and water
2b. Property Evaluation(soil logs)
P�1( I am interested in knowing in general terms the suitability of a parcel for septic system placement. (Fee$100 base,plus
1 $50/hr. after first hour).
Describe the intended use of the property and the reason for requesting the review:
PART 3: PLOT PLAN
Use the space to draw a detailed plot plan,or attach one to this application. The plan should include the following:North arrow,
precise location of test holes, location of existing septic system, dimension of the property, location of any drinking water
sources(wells, springs etc.),roads,easements, surface water,and other buildings on the property.
VLy�
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S. 76
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Lot Size: z. 14 AcrGS
Applicant's Signature: Date: IO— 2-1 _ 6
PART 4: HEALTH DEPARTMENT FINDINGS—OFFICIAL USE ONLY
Septic System
Yes No
❑ ❑ The septic tank was inspected by a certified septic tank pumper within the last 3 years and
was found to be in satisfactory condition.A pumpers report is attached.
❑ ❑ 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?
❑ ❑ Is a copy of a current Operation and Maintenance report attached?
Water System
Yes No Individual Water System
❑ ❑ A water sample was taken by health department staff and analyzed. Total coliform bacteria
were determined to be absent. Laboratory results are attached to this report.
❑ ❑ The well cap was inspected.The sanitary seal appears satisfactory.
❑ ❑ The well casing was inspected. The casing projected above ground and the ground was
sloped away from the casing.
❑ ❑ The well site was inspected.No septic systems,chemical storage facilities,manure pile,
animal 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.
❑ ❑ Records indicate the Water Facility Inventory for is current.
❑ ❑ Department files contain water system design and letter of approval.
Soil Conditions
Test Hole#1 Test Hole#2 Test Hole#3
0-/4° dam, 1S Q (od wed.hV.7
Soil Type: Soil Type: Soil Type:
Restrictive layer: �p� • Restrictive layer: /DO Restrictive layer:
i
Slope: ) �o Slope: a Slope:
Distance to Shoreline:bwll Distance to Shoreline: Distance to Shoreline:
Page 3 of 4
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 system has been in use on a regular basis for the last 6 months.)
❑ ❑ Sanitary survey? ❑ Pass ❑ Fail ❑ Suspect ❑ Not applicable
Water System
Yes No
❑ ❑ The water source consists of an individual well that appears to be a satisfactory
source of potable water for a single-family residence. The water was sampled and
coliform bacteria were absent.
❑ ❑ The water source is a public water system that appears to be in compliance with
the applicable regulations.
❑ ❑ Well Construction Permit ❑ Pass ❑ Fail
PART 6: COMMENTS
.JB/ls /�ii/.L/ �.m/lJi� nn Sloe 6P G S�.S�/h
INSECTOR YX.J DATE
Important Notice: Fin ' & d rminations of this review reflect observed conditions as they exist
on the day the evaluation was preformed. 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