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Home My WebLink AboutSWG Onsite Survey - 7/25/1994 2) As E� i -, ON-SITE SEWAGE SYSTEM SURVEY''-- �onF rKksars LOWER HOOD CANAL CLEAN WATER DISTRICT PROJECT: LHC AREA: ua RFr FATR DATE: 7� OWNER INFORMATION : TITLE: MR, MRS, MS (circle one). FIRST NAME: u7m LAST NAME: ADDRFSSa,367 c44 AQCA'D/4 CITY: -: WOtrVwm STATE: WA zip.'f OWNER'S PHONE: yZ� - O.K±/2 OCCUPANT'S PHONE: SITE INFORMATION (Mark SAME if same as above) PARCEL # 1az � 9 'C�" 00-08/ -I-A8"A oFNE ,so OCCUPANT'S TITLE: MR, MRS, MS (circle one) FIRST NAME: /A R 'k LL. LAST NAME: . /C �Po '' �,� ADDRESS: RRfFHl 1�2 { GFf CITY: STATE: 1�71 P. -" NUMBER OF RESIDENTS: WELL DEPTH �75tp2� l 373- 2z97(AP—`�- RESIDENCE TYPE: ( F - Full Time Residence; S - Seasonal Residence; R - Recreational Residence; C - Commercial; I -Industrial; M - Multi-family Residence; V - Vacant) ON-SITE SEWAGE SYSTEM TYPE: S Enter all that apply. (S - Standard tank and drainfield; P - Pressure Distribution; F - Sand Filter; M -Mound; T -Deep Trench; H- Out House; O - Other; U - Unknown /1AvA' A�Rex � T��lA INSTALLATION DATE /9 YEAR LAST PUMPED: Enter Year or U- Unknown GENERAL LOCATION OF SYSTEM: F-Front Yard; B - Back Yard; S- Side Yard; A - Adjacent Lot; U-Unknown PERMISSION FOR ACCESS TO INSPECT THE ON-SITE SYSTEM (Y/N) — (NOTE., Mason County Health Code provides right of entry provisions. However, our policy is to gain permission to access on-site systems. Your cooperation is appreciated and saves valuable time and money for Mason County. Applicable codes pertaining to this matter will be provided for you upon request.) SIGNATURE � DATE 9-") Comments: Is// L AC K DO YOU WANT TO RECEIVE INFORMATION ABOUT WATER CONSERVATION? (Y/I� Rcvmd May 27, 1994 I i J • Lower Hood Canal Field Inspection Form • Address: a-IWY 3- �3Ct.,F-Ar1E Owner/Renter: C.rrx y rues rJ'i' Permission to Inspect(y/n) �, Date: q ' 4 Inspection and Dye Test Information Inspector Initials: (4+1- 5 Inspection Dates: Level 1: Level IC: Level2: Visual Site Inspection Data: Setback between septic tank and surface water: l00} ft SurfaceWaterType (Marine, Stream, Ditch, Curtain Drain, Other): 2: 4 Setback between septic tank and well: 0 14 ft C mT -S's Setback between drainfield and surface water: A f9f9;' ft Surface Water Type (Marine, Stream Ditch, Curtain Drain, Other): 3� Setback between drainfield and well:iii ft Reserve drainfield area (y/n) Bedrooms Interceptor drains (French, curtain, roof foundation) (y/n)_ Other(IargeOn-sites,Complamts,other): V!dLA Septic System Status and Priority System Conditions: Failure Classification: C D = D,un2 a to drainfield P = Pass SHW = indications of seasonal high water F = Failed WP = Water seeking plants over drainfield 'L = Limited (one Condition) LG = Dense, lush grass over drainfield PIT = Pre-failure (two conditions) SD = Slowly draining plumbing fixtures S = Suspect (uncertain conditions) PM = Indications of poor system maintenance BW = Indications of high water usage Failure Type: Failure Priority: D = Damage to Drainfield 1: illness or injury related. B = Broken Influent/Effluent Pipe 2: Visual Dye, open or surfacing sewage entering H = High Water Table surface water, outhouses or cesspools with G = Greywater Discharge <3ft vertical separation from SHW. S = Surface Water Intrusion 3: surfacing, seeping effluent not entering surface O = Other water. 4: Other unacceptable installations,intermittently Other Type: failing systems not entering surface water, effluent over tank baffled. 5: primarily sesthetics (odor). Observations: C e 9 Dye Packet Results Background Series I Retrieval Series 2 Retrieval Series 3 Retrieval l Site M Dam Dem Dam Dam Dam Dale Dam Dare Rcaule Result Rcaulu Result Placed Rctneve Placed Retrieve Placed Rcaicvc Placed Retrieve Bacteriological Water Sample Results Site # Date Results ' x TauRSTON-MASON HEAITt DISTRICT N c3dyo. �1,:1-= a aim Division of Sanitation Court House Annex q Court House Annex Shelton, •.!ashington a 3 ' 01 I - Olympia, Uashington !� Phone 426-8515 Phone 352-4851 j APPLICATION TO CONSTHUCT-OR ALTER AN INDIVIDUAL SPIAGE DISPOSAL SYSTEM l (Application required for each installation) property Ouse Telephone l/r :�i 6 7_ Z c /� Flean Print 1�11ine pdd�e�ae f . . Q 's-9 2 WA Addrbe's or Site T crc[�so.tl PcUc. -� Location of Property, c : lot '/�_ Bloe-k,,, Detail9d directions lto ite: .4 �.-T -/' / ; "A 1 proner'ty - Commercial S1ze_24_V_7 a L Residence No. Bedrooms Beeeman_f,_Typ Vater Supply= '.!ell Springy Other Ie any eater supply or body of water within 50 feet of savage syfltem. Yes— No-Septic Tank /A b a ,gallons. Drainage System Length feet. Trench Vidth a3'Ft. (Refer to Table 1 of Bulletin) (Baker to Table 2 of Bulletin) And/or system other than above -.r .Check for Installation of a .. Automatic Laundry V9 Automatic Dishwasher (NII) Garbage Grinder (W) Is Contractor installing septic tank? yes `! No Drainfield? yes-�/no_ Name of Sewage Contractor � d _ - SewaW contractor must be licensed by Thurston-Mason Health District SEETCH PLOT PLAN AND PLANS OF PROPOSED SYSTE4 ON SEPARATE SHEET OF PAPER THE UNDERSIGNED hereby applies for a pe t to constru t a new O sad/or . . alter O a savage system on above propent i a th the Bulletin. Applioeat Is Sigoa � " �p c Address_ Bulletin Vaehingtou Stute Department of 1palth Bulletin -.S. No 1 entitled Septic Tank 'ystem for Your Home for minimum requirements. -- - // . --- (Not to be filled in by Apulicant) - "-- ---_ ._ ._ . . .._- --- Permit No 2 -, -/_ Fee�l' -_ Dste Issued_ j - a Area ._ San�.x__.-_1_. ----_.--. .._ _ _ '- .Sanitarian-- .------------- • Dates Inspected Date Annroved -.q=.fQ-4 _ A- By,J�_ $ --- .___ :-pproved S itartan 3 1 DRA1N t i��D II 6LB N 0.7 VFLUE v r 1000 - j �- TPrJ�' DISrK�$NY10N II LOWER HOOD CANAL FIELD INSPECTION FORM tiff Initial Information: Area: 41 Added to database(Y/IV) Owner Name: Permission to Inspect?: Site Address: Di 3 Appointment Required ?: Parcel#: Appointment Date; Occupant Name: & R.1 k.504 vhyC9s- Inspections: Level 1: -Z G�7 - Level IC: Level2: S S Inspection Team: .� Updated database(Y/N): Inspection Results: - Distance between septic tank and surface water: 1 DO F (ft) Distance between septic tank and well: CO vrn (ft) Distance between drainfield and surface water: Distance between drainfield and well: P ovvt (ft) Occupancy (occupants/bedrooms): Other(Larger on-site, business..etc...): eoyv ✓ 'eE c�czj ✓ The septic system appeared to be functioning at the time of the inspection; no obvious problems were observed. The drainfield area may be compromised due to vehicular traffic. (i.e.: parking, driving) _ There are indications of poor system maintenance. (i.e.: lack of regular pumping, leaky plumbing, slow drains, excessive chemical dumping, high water usage) _ Construction was noted in the drainfield area. Sewage was observed entering surface water; confirmed by visual dye and fecal coliform count of>200fc/I 00ml. _ An unpermitted outhouse was observed. Other: Additional Comments: System Classification: Pass: Fail: Suspect: Failure Priority: Pnm un 1: Ilhrw uJury rt.W W.2: VuuJ Dye, mJring l M1ouaea yr ccvapoals wiN <Ift VCM1.SCP.from Sn .I: Surfecmg eugNg elauwt vd waling wRace weer.O:UNcr uwcc Wubk inalalktime;wtum�vrnJy failing[yekma na rn�enng eurfKe wYcr.5:Pmm My w cs(odor) SITE DIAGRAM 411 fw� �WkS tf 60 — DYE PACKET RESULT Backgound Sena t Sile Relneval Sena 3 Re .] Sena 3 Retrieval Number Dale Date Resulla Date Date Raulu Dale Dale Raulta Dalc Dale aced Results Pl R .. Placed Rctrievc Placed ft tr ve Placed Retrieve ti� a7 q h p 5 j„ A z 3 � � a BACTERIOLOGICAL RESULTS Site Date Results Number