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Home My WebLink AboutCRT2021-00006 - CRT Loan Cert. / EH Review - 5/21/2021 415 N MASON COUNTY SHE TON:30-42756 0, EXT.4 0 COMMUNITY SERVICES BELF :360-2754 0 C67,EXT.4 ELNIMA:380.482-5269,EXT.400 Bulldhg,mannin4r Wmm UtO altRCommunity ith FAX:360-427-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW Permit Number Payment Information Type of Review V -Lay1 . SepticandWater $370 ✓ Receipt Number 1 Septic $210 ❑ Cash ❑ Water $220(Individual and Two Party) Vcheck ❑ Group B WS$80.00(+$80.00/hour beyond 1 hour) Date of Payment � ❑ Property Evaluation$305 ��' ❑ Resample $29 lab fee Instructions: Complete Parts 1, 2, and 3 completely and accurately.With the application form, please submit the appropriate fee and the necessary documents such as a septic system maintenance report. If the application is for a property evaluation for septic, be sure the test holes have been dug and the location is clearly marked at the site. PART I. APPLICANT AND PARCEL/I�DENTIFICATION / �1 ,c Name of Applicant ,�vMP7/t f�DQ007J SA�C�N 1 Phoneaw � Ji7o2S�6 Mailing 1A�dresso/�Applicant 07j SAS/ 5/�%lG �U /O(o City U/�lo/� state 1j)q_ Zip 99,59A 12-digit Tax Parcel No. 3 '� el a.C— S 2 — B c le 1 O Site Address ��i-A 4r �.4T gaJ-r6 1,nIo Brief Legal Description Driving Directions 26 Page I of 4 This form may be scanned and available for public view on the Mason County Web site. ❑vis d U 18 PART 2: TYPE OF REVIEW u Septic System • Age of system • Age of house I ks • Number of bedrooms • Name of last owner „vE mc.TnlrR� • Is house currently occupied? YES L NO • If not occupied, how long has it been vacant? Water System • Number of service connections on the water system? n^g • If a public water system,name of system • WFI number ` n 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 review. T 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 Test 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) SEC �}TI/�Gl F�11�—�✓ ' LOT SIZE X Acres COMPASS Applicant's Signature: Date Page 2 of 4 This form may be canned and available for public view on the Mason County Web site. Revised 1/2/18 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-she 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 Public Health staff. 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 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 form is current. ❑ ❑ Department files contain water system design and letter of approval. Soil Conditions Test Hole#1 Test Hole#2 Test Hole#3 Soil Type: Soil 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. Revised 1/2/18 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(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 coliform bacteria were absent. The water source is a public water system that appears to be in compliance with applicable ❑ ❑ regulations. ❑ ❑ Well Construction Permit [] Pass [] Fail PART 6: Comments Inspector 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. 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'gel •2 7rr,s7 ire y FA — U.,, Fropert) atI for OAY Th6 L e f, Comme¢ia Size Residence/• pad'. is Basement_ Type Water Supply: Publi< Well Spring Other — Is any water suppy or of water within 50 feet of""go system%.&s _ No---tS� Septic Tank gallons. Drainage System Length C'VWe_ feet. Trench Width feet. (JW.b T.6 I I BAW.)• (Bah•to Table 2 1 8.9.W)- And/or system other then+hove — — Check for Installation of. Automatic Laundry ( ) Auomatic Dishwasher ( ) Garbage Grinder Is Contractor Installing septic tank? Yes, No — Dmird'ield% Yes✓ No — Name of Sewage Contractor r aE+WE CONreNCTO+..a, of lK[NSE W TNegaIONJafON M LTN apiRlCi SKETCH PLOT PLAN AND PLANS OF PROPOSED SYSTEM ON SEPARATE SHEET OF PAPER THE UNDERSIGNED hereby appliev for a permit to consbuck a nw ( Y ) and/or alb, ( ) a+wage system on above property in accordance with he Bulletin. Applicant's Signahre -- Add,e.. /d/T 06 •gelAee.• W.hm,m. Stare D.paAm.nf of Health Bun en B. S. No. 1 wifl.d "A Septic Took Spa. A,, Y..r Hem:'hr m,nrm.m r.gair.m..h. INOT To es wusp w sr apxxann Permit Fos, ./6 Date Issued ------- BY._ti" jC?6.=-.-.................... Area __.__._.......................__._..--._..-.._...._......_.__.-__....._ $onitarian ................................................... ........................... DatesInspected .-__-.._— Remerks--------------_-.—.--_................................... ........................... ....-.--- ...... .. ---- -.... . .. .. .. ... .. Date Approved =�1= --------- ---- -•--"-----'------.....---- —._....------_- - PUted from Mason QOunty DMS ' parr,T=o f.o�n L,92:=•arr County DhAS Thurston County Environmental Health j 2000 Lakeridge Dr.SW •Olympia,WA 98502 360 867-2631 nr�c�tm��' k2k COLIFORMBACTERIAANALYSIS Dap Sample GoINOCled Time Sample Camry L�51�71?W1 SEE �I Hamad uNm Ile �� Typeo(Waler SyslemWedkatdyanebox) .J Pdvale Housemaid ❑G.,A ❑GmupB ❑Oder Gmup A ON Gaup B Sy a ms-Provltle hum Water Fadli les Im mary(YyFI): System Name: Cmlaet Person: ICC Goa t.alea_ Day Phae:( ) -9b NZ) CNI%nna:1L 3J3 EmekIaCN GN+Ie- Co.Na w E e:l 1 BealewYM:(PMLd me,W W wadDoade aemaeawdnsl SAMPLE INFORMATION Sample mlkaled by(-MY 1 Vk� C,GNG�t�- Speaik 1. a Or addresewharesamplo a ed: S�edal Nslpti p,mmmen% I %C>—I t @ w lq I ply 1'tec.yr, 5UL At Typeoi Sample(must ded mly One boaa(gt bmmlh pd listed below) 1.0 Roudne DISMbudon Sample 2.Repeal Sample(Oft'uneaL routine) Chbnnated:Yes_No_ ❑Dis WWO SYSOM Chbdne Rev&W:Total_Fina_ Ch1W,m d:Yes_No_ 3.Raw Waler Source Sample Chbmne Residual:Tolet_.Fred_ ❑E.sea'-GWR(AR) ❑Feel-wma.am.,PaerPmw•ral UmmastadM meme leb number Fdmmc:Ys_Pot_ __ _ ❑AsseasmaMMpmbmg(NP) Unsadsiadwymutino Wleddala: Oahe, S a mple orin�--1-0*Inresdgadre_ _ aMr ` -'-'T LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY UneAsticlary Total Wilum Presentand ❑aatiedamq ❑E.ca4 present E.coeabsant NO Cofdowe deleded Repinemem Sample Required: ❑Samplabodd(,Mi,Opts) ❑TNTC Badetial Deta9y Resulle:Told COMam 110pm1. ECOi IIIIOmI. F=1 CONon ItO0ml Emem dOOml. Mdlad Cade: SM92238 OSM9222D DNwd�am�yna Rxe'nxe: CA ❑SM92150 OE-IpWi BOO�I taws ena T:renrvaaa: - Dm Repedea:$2 - e/WNURamoxtinesPwMedbi 19EUH OnIy'. 0 8 0 _�6a7 oatynwi.t �.aptnst Thurston County Environmental Health 20001akeridge Dr.SW •Olympia,WA 98502 360867-2631 TIIumTON couolW 01— COLIFORM BACTERIA ANALYSIS Date Sample CoPotNd Timm Sample County ObIO" Coleded yoyl )I:tJow Nflbe*) Tyye of Wafer Syslem(cfied onN one boa) Pdaa HauehmM ❑Group A (3Gmpll ❑Other Grmp Aand GmupBSystems-pmadefrom Water FadlosIn.e my(PIFII: IDp _ _ _ _ - - System No= Contact Perron: Day Pro-'. Cell Phae: ) 3 Email: Iloc. LL o M> Fh smameum b:IRinM rem.ease.asaapmm venesem wl 1 -t �OV6 SAMPLE INFORMATION Samplealbcureby(name): L_ Ik'_ CeA%Vuli Spedecloalbnmaddreaswhereampkallecled: Sped6lnsWOAomor amm�mb: Ito II C wA -rob P .aLc � l Typedf Sample(muatdcka"yembmtofgl Nmugh baWWb ) 1.❑Routine Dlebibu8on Sample 2.Repeat Sample labor utmat.rout;-) Chlodnaled:Yes_No_ ❑Dismbmlon Sysem Chbdne Road.*Total_Fina_ Chbdnatol Yes_No 3.Rew Waler Source SBnspte Chbnne Residual:Tolal_Fme_ ❑E.cog-GWR(AIP) ❑Fecal-Su ,,mm.wrce(maa") UnaetlsfedarymuRu Ob number FIIION'.Ym_tb_ __ ❑Av-ament Monilaing(AT) unnuebbi mudw collect dale: 00ther S 4.XSample Collected for Inlormaflon Only yaearygeb._ Cansbubonl Repars_ Ober-c-I'l LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑U-atishctery Tolel Conform Pmsnk and C micwrytled ❑E.ocapre"m ❑EcoA'absem Reptecemant Sample Required: 0Sampleboold00houre) ❑TNTC o Bacterial DensityR .fts:Total Caimm NM. Ecau N00ml. Fecal CalloOn 100m1 Enlmo»u 100"n Atedsk Catle: SM 8223E ❑SM 0271D paleerd ime Romiad � SM B2158 ❑EntemlmlQ) (p-a al mream rmeA,rrmd: a Ikle Bem-d: -2 smxxomenmam�ewWsndsNl �OeN 0 8 0 omra.wsautmsxemnm