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Home My WebLink AboutCRT94-00034 - CRT Application - 2/15/1994 MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTON, WA 98584 (206) 427-9670 FAX 427-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW Receipt No: zuj Date of Payment: septic: Review: Water Review: Property Evaluation: INSTRUCTIONS 1. An application is considered complete when the fee is paid, Parts 1-4 of the application form are twplafed. (assistance will he provided upon requmet far coepiseing Part 1wo), the necessary paparerk is attached, and required soil .1hacion holes have bean mmavated. 2. After a c®plated appliratioo is racaived, staff will Ina ent the Property and provide the applicant with a written report. 3. If the project raqulres the excavation of m rs than 3 test holes, the depactment my chnige the applimnt an hourly rate of $37/hour as set forth by the Mason County Bashi of Beslth. PART 1: APPLICANT/PARCEL IDENTIFICATION :...................................::::::::::::::::::: ..................................................................../.............................................................................................................. NAME OF APPLICANT $2�� I �)'y) ( F � .27 /3aPHONE ( ) SITE/HOUSE ADDRESS I((c��7 I Imo(i/c�?(� ' GL MAILING ADDRESS 9 V• t a.Ce ACREAGE mar ASSESSOR'S PARCEL NUMBER LEGAL PROPERTY DESCRIPTION SUBDIVISION (If Applicable) r�1 n ('� 1 DIV BLR LOTT 1. DI CTI NS FO LOCATIN SITE Oka rly(�1(y �}� �� A\U . ( ( D�k IIIL� Luc �k �1a�6-rWC, 41 r G& 0Ll Sketch location of property in this apace. YO. S1 seviaed 12/28/93 PART 2: PURPOSE OF APPLICATION 2AA../'� OPTION ONE ' (-gyp I am applying for a bank loan and the bank has asked for an evaluation of the ` 1 following: �septic system (Fee: $50) • Aga of system • Age o1 House • Number of Bedroom. • Neme of Last owner • Ia house currently occupies? • Attach pumper'+ report, dated within last 2 years, stating whether the system was pumped, the sire and condition of no tank, and no Condition o1 the baffles. ❑ water syerm (Fee: $40) • Number Of service corrections on water system if public water eystm: Both (Fee: $68) " •��` • Prwlde information sham sows for both septic and water systma 2B. OPTION TWO I am applying for a building permit, and environmental health has required an evaluation of the following: AXSstiug septic system (Fee: $50) • Age of system • ember of Bedroom • None of Last owner . • Is house currently occupied? • Attach pauper's report, dated within last 3 years, stating whether "a system was pmped, the sire and condition o1 can rank, and ran condition of the battle+. • If the original septic permit cannot to located and system lees than 5 years old, apply for now an-sire Sewage disposal Permit. • If the original septic permit cannot he located and system mre than 5 years old, submit signed w-built drawing from certified designer or professional anginmr. Reserve Ares for Future system Nepair (Fee: $40) • 1wo properly m:cavated pirs are 4 ft deep must be ready for inspection by the department. math (Fee: $50) Prwide information sham above for both septic System and reaarve area 2C. OPTION THREE I am interested in knowing in general terms the suitability of a parcel for septic system placement. (Fee: $40 + $37/hour) Describe no intended use of the property and the reason for requesting the review: In. 5t Rev!eed !i/20/13 PART 3: PLOT PLAN One Nis apace to Evan a detailed plot plan, or attach one to "is applicatim. A detailed plot plan In am that shwa "a ptaelae location of the met toles, existing septle ayetass, dimensions at the property, and location of any wllc, roads, or other building. on the property. PART FOUR: AAUTHORIZATION p APPLICANT �l O ( n'/'i DATE 49 PART 5: HEALTH DEPARTMENT FINDINGS - OFFICIAL USE ONLY 5A. DETERMINATION OF APPLICABLE STANDARDS . . - The prrieimary drainfield area mat meet the following standerda: !2 Neat current standards Standard marine system El No overt failure Not appllcablm. The reserve dralnfield area must move site characterletlee that could support a septic nation Chat wind set the follcwiicg standards: 1Kmeet Current standards. 0 wet marine repalr standards. Neat marine expansion standards. Net eppllcable. 5B. WATER SYSTEM YES NO INNIVISUAL MATBA SYSTBN A water sample was taken by health department staff and analyatl. Total Coliform bacteria were determined to to moment. Lataraosty results are attacMd to Nis —part. Me well cap was inspected. =a sanitary seal appears satisfactory. Me well casing was inspected. The casing projected above ground and ground was eloped away from the caning. Me well site mare fnspectsd. So septic aystms, Chemical etaraga facilities, manure piles, animal feed In., or other obvloua soureso of contamination were located within a loo fact radius of the well. PUBLIC HATBR SYSTSN Records indicate water sampling regulrments are being satisfied. El El Records Snnicaca the water Facility Inventory form is current. DEl topertmnt films contain no information Indicating the system is at of Compliance with state or local water myatm ragairamects. 5C. SEPTIC SYSTEM YES NO Elno septic tank was Snapents, by a cortSfled septic LN[ pamper within the pant 2 years and load to be In matisfactoty condition. A pumper's evaluation is attached to thin report. Recorda for this property Contain a septic potedt, design (if required), final inspection approval, and as-built approval. Me dralnfield site was inspected, and appears consistent with recorded documenrs. El The dralnfield area appears N he maintained in an acceptable manner. Me dralnfield area (the area whato the dralnfield is assured to be located based on office records and/or observed site cendltons) appears N be maintained in an acceptable cancer. Me dralnfield area (the area where the dralnfield is assumed to be located based an office records antl/or observed site conditins) show no indication of wort failure at the time of inspection. No. 51 Revised 12/28/93 5D_ SOIL CONDITIONS TEST-HOLE it TEST HOLE Y2 TEST HOLE i3 Depth of root pen. : Depth of root pen. : Depth of root pen. : Depth to restr. layer Depth to restr. layer Depth to restr. layer Soil Type: Soil Type: Soil Type: Vertical Separation:- Vertical Separation:" Vertical Separation:- Curtain drainable? (Y/N/NA) : Slope (i) : Shoreline? (YIN) : Minimum lot size:" Designer level: ' va[utal separation S. the depth of .nseturated, original, unai.tucMd Soil or Type. 2-6 that ssl.ta beb«h the bottom of the sob.utface absorption system and a re.erittive layer or the raterNble. vertical ..paration for purposet of designating designer level will be calculated by the health departeent based on a 12-inch deep 5E. OTHER NOTES AND COMMENTS ro. s1 Revised 12/20/93 PART 6: HEALTH DEPARTMENT DETERMINATION - OFFICIAL USE ONLY 6A. PRIMARY DRAINFIELD SYSTEM The primary drainfield area was inspected by staff and pertinent records were reviewed. The following determination has been made: rVI lot The system appeared to be functioning adequately at the time of inspection and and meets current design standards. The system appeared to be functioning adequately at the time of inspection. Not applicable. Comments: 6B. RESERVE DRAINFIELD AREA The reserve drainfield area was inspected by staff and the soil was evaluated. Site characteristics indicated an area exists that could support a septic system that would meet the following standards: Current standards. Marine expansion standards. Marine repair standards, Treatment Standard Not applicable. Comments: 6C_ WATER SYSTEM The water system was evaluated by staff the following determination has been made: 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 found to be absent. The water source is a public water system that appears to be in substantial compliance with applicable regulations. Comments: ....................................................................................... .....ee:[Ea existed on the day Findings and determinations of this review reflect observed conditions y Y the evaluation was performed. Absolutely no claim is made by this office, either expressed or implied, concerning future suttees or failure Of the systems and alone evaluated. Resource land and critical area checklist may be required by Department of community development prior to issuance of developmental Pettit. a� INSPECTOR DATE yo, sl aevieed 111,VU