The URL can be used to link to this page

Home My WebLink AboutCRT2024-00005 - CRT Loan Cert. / EH Review - 10/14/2024 MASON COUNTY fib NeTMSTON.3 -HELTONWAE%99564 SHELTON: 6027-9670, T.400 BELFAIR:360-2754467,EXT.400 Public Health & Human Services ELMA:360-F8A2-5269,EXT. ?779�6 OCT 1 6 2024 D APPLICATION FOR ENVIRONMENTAL HEALTH REVIE ey ! — --- en Infor t - T e i w parmk Number 20 r ❑ Septicand Water yL15 .,./CRT Receipt Number ❑ Septic WA.- .5 2 _ � Cl Cash 1( ) Water $266(Individual and Two Party)4'PtG g Check ❑ Group B WS$95.00(+$95.00lhour beyond 1 hour) ❑ Property Evaluation$35e 3U5 Date of Payment D Resample $as lab fee Instructions: Complete Parts 1,2,and 3 completely and accurately.With the application form, pleaselica subs it tha ppropriate fee and the necessary documents such as a septic system maintenance report. If the app properly evaluation for septic, be sure the test holes have been dug and the location is clearly marked at the sit a e. PART 1. APPLICANT AND PARCEL IDENTIFICATION Name of Applicant�4f� A n� SOB �C Phone, M/KKK/ S Mailing Address of Applicant r�Y✓ s ! City � Stale 6& lA — 12-digit Tax Parcel No. 32/3 / —//- 6DDOO Site Address 06 l'f e5' /'4/Lega6zl Brief Legal Description i�iasef/ Driving Directions %%1{LiA.] a AAdr/ZDy TURN /OAS MiKdc`2st�k1 � 1QNn FOLL0L�J -7 + A00/2tSS f/ rj Lcf�z S200,f !1F yf—y 1 Page 1 nf4 This form may be scanned and available for public view on the Mason County Web site. srd 12i8/2622 PART 2: TYPE OF REVIEW ❑ Septic System • Age of system • Age of house • Number of bedrooms • Name of last owner • Is house currently occupied? ❑YES ❑ NO • If not occupied, how long has it been vacant? p/Water System • Number of service connections on the water system? • If a public water system, name of system • WFI number ❑ Property Evaluation (soil logs) Property evaluations provide, in general terms.the suitability for a parcel for septic system placement. THIS DOES NOT GUARANTEE FUTURE SEPTIC SYSTEM APPROVAL, • Describe the intended use of the property and the reason for requesting the reVIOW. PART 3: PLOT PLAN Use the space below to draw a detailed plot plan,or attach a detailed plot plan to this application.The plot plan should include the following:North Arrow, Location of Teat Holes, Location of Existing Septic System, Dimensions of Property,Location of any Drinking Water Sources(wells,springs,etc.)Roads, Easements, Surface Water, and Buildings on the property. (skip Part 3 for Group B water system review) LOT SIZE W�.LL �.617 X yn7 II Acres NOV 5 L- COMPASS Applicant's Signature: Date OC7 ��y Page 2 of 4 This form maybe scanned and available for public view on the Mason County Web site.Rsed 12/8/2022 PART 4: HEALTH DEPARTMENT FINDINGS —OFFICIAL USE ONLY Septic System Yes No The septic system was inspected by an appropriate maintenance provider and the submitted report ❑ ❑ Is current. ❑ ❑ 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 Individual Water System Yes No A water sample was taken by Public Health staff.Total coliform bacteria were determined to be Ij ❑ absent. Laboratory results are attached to this report. ❑ The well cap was Inspected The sanitary seal appears satisfactory. The well casing was inspected.The casmg projected above ground and the ground sloped away ❑ from the casing. The wellsite was inspected. No septic systems,chemical storage facilities, manure pile,animal ❑ feedlots or other obvious sources of contamination appeared within a 100-fool radius of the well. Yes No Public Water System ❑ P Records indicate water-sampling requirements are being satisfied. ❑ ❑ Records indicate the Water Facility inventory form is current. ❑ ❑ Department files contain water system design and letter of approval. Soil Conditions Test Hole#3 Test Hole#1 Teat Hole#2 Soil Type: Soli Type: Soil Type: Restrictive layer: Restrictive layer: Restrictive layer: Slope: Slope: Slope: Distance to Shoreline: Distance to Shoreline:_ Distance to Shoreline: Page 3 of 4 This form may be scanned and available for public view on the Mason County Web site. 12I82022 PART 5: HEALTH DEPARTMENT OBSERVATIONS — FOR OFFICIAL USE ONLY Primary Dralnfield 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.) [l Ll Sanitary survey? ❑ Pass ❑ Fail ❑ Suspect ❑ Not applicable Water System Yes No The water source consists of an individual(or a two-party)well that appears to be a satisfactory source of potable water for a single-family(or two single family)residence(s).The water was ❑ ❑ sampled and ooliforrn bacteria were absent. The water source Is a public water system that appears to be in wmpliance with applicable ❑ ❑ regulations. ❑ ❑ Well Construction Permit ❑ Pass ❑ Fail PART 6: Comments Ca�S � - _I - , ��`� � Inspector � ib W�ld� VI Date Important Notice:Findings&determinations of this review reflect observed conditions as they exist on the day the evaluation was performed.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 This form may be scanned and available for public view on the Mason County Web site. sed 12/8/2022 i � l A Y � rn i Printed From Mason County DKIS PriMal from Mr- GvAm i^MS I jC412 urston County Environmental Health Ully Rd NE♦Olympia,WA98506 360867-2631 OLIFORMBACTERIAANALYSIS Oale Sample Co nmsw le Cant') 15 r MahonM TyPeofWeMrSplem(oheoltonryone box) pdvria%ard01d 511a73 ❑Ga ❑GrapB Over CmpAAWGnwpB6Y318m-ft"k=Waler FaCO aIrmmbry(WFry 101 SyeMm Norna: (ox N0a\001 6NAIT-FC/lu�l ComadP—: R15on p OeIfPhom:l O) CORR.,/ I Ill 1 r19 UN 1 _ th. om- islj/1 n� 6n wgfyw4.-.,9UJ -Fnv2r4 l�l'Y. SAMPLE INFORMATION Sempballecled by(nRre)• )Q4y �}10YY1 $11� Spedac kcaticn oreddresxfiyeN-re9leampboowed: Spedd valnx:aNlr �s0l Mil<Xelceh� QIS. 'and�l TyW N&mpN(mrel Mackonyo��a llboxall wouphN GkE bdan) . I. 11"oletdbudw Semple 2.Regal Semple(eller umeL radln) r Sled:Yes W-2— ❑DMibudon Bpbm MorM Retliuel.Tolel_Frea_ ChMrebd:Yee_No_ 3.Raw Weler Source Sample C*me Residual:Total—Free_ ❑E.col-GWR(AP) OF"-te xua.. V..rema) Unx5abdwlmboolebnmbr. Fllrod:YN_Na_ ❑AWa nllklw g(AN) UnntlNegoryrpdM ootleddetx Clover 9 a.IP Sample Collected forinfomaeon Only vreNgave_ ConW knlftah _ ONer_Q�/�((��"" LOAtJ LAB USE ONLY DRINKING WATER RESULTS LAp USE ONLY ❑UneaNefeclary Tdd Colton Pre enland SMlsfacto ❑EWpreeenl ❑E".1,0e41 de4Ged Replaoanenl Semple Required: ❑SanpNnoonpsahoucs) 137MC ❑ Badvu10e1WryRendlc Taml CAawm_J100mL EeoY yIOSmL Focal Cdif m IloSM EdemmcL____Jl00nt LVWW �W!12230 OSM9=92I B ❑Enb=bm1Q• �' • aRJ�+We+appi