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Home My WebLink AboutEH REVIEW - LRG Application MASON COUNTY 415 NSHELTON:360-427-96 0.EXT 00 COMMUNITY SERVICES aELFAIR:360-275-4467,EXT.400 ELMA:360-462-5269,EXT.400 aaa.s.euccin%Eninmm..ledthCe my hffi FAX: 360-427-7796 APPLICATION FOR dLANDUUSE EVALUATION Amount Paid: 4^ 655 2 Receipt Number: xl�.3—o5J3o Instructions 1. An application is considered complete when the fee is paid and the following 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.Properly excavated pits are 5-feet deep with a 4-toot deep shelf 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 Health On-Site Standards) ➢ A scaled plot 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 any existing or proposed wells,roads,or buildings within 100-feet of the property boundaries. 2. After a completed application is received,staff will inspect the property and provide the applicant with a written report. Important:In order to avoid additional costs,be sure the test holes and parcels are all flagged and clearly delineated as to lot and test hole number.The ldentifled test holes must match the locations shown on the proposed plot map. PART 1 : APPLICANT/PARCEL IDENTIFICATION Large Lot Subdivision ❑ Subdivision ❑ Short Subdivision `` ❑ BLA Name of Applicant J�^'t +ab'.n f�ecl'�S Phone 3w 341 9S16— Mailing Address of Applicant -1`ll SF C6*L ef. + r—a' R.1 city sk-U., state (.3K zip gbs-S4 12-digit Tax Parcel No. t-U V t. • H , mo0o Property Legal Description Lot Siza (Acre rSquare Feet S•31 S' Zia 5- 004 S-`�'g S'yo S•�f --COT_1 L0T2 LOT3 LOT4 LOTS W'11- le Directions to Site IeA laaagaaaa PART 2: INTENDED USE OF PARCEL Intended Use of Property(Check One): Single Family Residence El Residence [I Other, Specify 'K Wate Source for Parcels(Check One): Individual Wells ❑ Community Well(Public Water System) This form may be scanned and available for public view on the Mason county Web site. Revised 3l2/2017 PART 3: HEALTH DEPARTMENT REVIEW (official use only) Soil Logs and Site Characteristics Lot# Lot# Lot# Lot# Test Pit A Test Pit A Test Pit A Test Pit (15 0 -(ZL5 G-Gj- ti C Ou cot,rZ& c Depth of Mottling Depth of Mottling Depth of Mottling Depth of Mottling Depth to Rest. Layer Depth to Rest. Layer Depth to Rest. Layer Depth to Rest. Layer Soil T e (USDA) Soil y e (USDA) Soi11, � (USDA) So' T e (USDA) Test Pit B Test it B Test it BTesi k B Depth of Mottling Depth of Mottling Depth of Mottling Depth of Mottling Depth to Rest. Layer Depth to Rest. Layer Depth to Rest. Layer Depth to Rest. Layer Soil Type (USDA) Soil Type (USDA) Soil Type (USDA) Soil Type (USDA) Curtain Drain Curtain Drain Curtain Drain Curtain Drain Needed?_ Needed?_ Needed?_ Needed?_ Slope % Slope % Slope % Slope % Shoreline? (Y/N) Shoreline? (YIN) Shoreline? (Y/N) Shoreline? (YIN) Minimum Lot Size' Minimum Lot Size' Minimum Lot Size' Minimum Lot Size' This form may be scanned and available for public view on the Mason County Web site. Revised 3/7/2017 PART 3: HEALTH DEPARTMENT REVIEW (official use only) Soil Logs and Site Characteristics Lot# Lot# Lot# Lot# Test PIA Test Pit A Test Pit A Test Pit A o #� 0 -2-o S ll '10 e GGS 20 -5O eG CS 4'r Depth of Mottling Depth of Mottling Depth of Mottling Depth of Mottling Depth to Rest. Layer Depth to Rest. Layer Depth to Rest. Layer Depth to Rest. Layer Soil ype (USDA) Soil pe(USDA) Soil Type (USDA) Soil Type (USDA) st Pit B T t it B Test Pit B Test Pit B Depth of Mottling Depth of Mottling Depth of Mottling Depth of Mottling Depth to Rest. Layer Depth to Rest. Layer Depth to Rest. Layer Depth to Rest. Layer Soil Type (USDA) Soil Type (USDA) Soil Type (USDA) Soil Type (USDA) Curtain Drain Curtain Drain Curtain Drain Curtain Drain Needed?_ Needed?_ Needed?_ Needed?_ Slope % Slope % Slope% Slope % Shoreline? (YIN) Shoreline? (Y/N) Shoreline? (YIN) Shoreline? (Y/N) Minimum Lot Size' Minimum Lot Size` Minimum Lot Size' Minimum Lot Size' This form may be scanned and available for public view on Ore Mason Oxmty Web sae. Revised 3/2/2017 `Minimum lot size applies to new subdivisions and is defined as the minimum allowable land area per residence or residential equivalent ((4550 gallons per day). COMMENTS nr lJak '� PART 4: REVIEW SUMMARY 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 Date PART ;7M_ Z Date This farm may be sunned and available for public view on the Mason County Web site. Revised 3/2/2017