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Home My WebLink AboutCRT2024-00004 - CRT Application - 9/11/2024 594 MASON COUNTY 415 NeELTN:36SH7-967 WXT.400 SHELTON:360-427-9870, EXT.400 Public Health & Human Services BELFAIR:360-275-4467,EXT.400 ELMA:360.482-5269, EXT.400 FAX:360427-7798 APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW r Permit Number Pavment Information Type of Review CRT Receipt Number ❑ Septic and Water $430 I( Septic $255 0 Cash�,,.� ^ N r' ❑ Check ❑ Water $255(Indlviduai and Two Party) ❑ Group B WS$95.00(+$95.00/hour beyond 1 hour) Date of Payment ❑ Property Evaluation $350 ❑ Resample $30 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 1. APPLICANT AND PARCEL IDENTIFICATION Name of Applicants 1co NSun C/O &h➢N TZ(L CY—Phone 360 -NQU -c1g26 Mailing Address of Applicant 920 24 tlrar d Avenue city Site Ijk'� State W R Zip %56Lf 12-digit Tax Parcel No. H Z 123 - 77 - C0030 AddroiS if nail- Site Address xx)e E AMv (*_CA- She lbw. I W A g9684 l asVt "% JJ Brief Legal Description TrwLc -3 aF 41t IJ SAbAylfim 0. 13 Afro 537872 Driving Directions Hwy 101 `b C. E rk 6-How 4.6' AM C-4 on 141. Follow to wtJ Jj fins. road o,,k Fh b 11cA4:, FLI'V. All- g�rnl�. Road Clec,'A inlO ProPrr4„ a d fjVp 616 on !'fie, I OFF. Page l of 4 This form may be scanned and available for public view on the Mason County Web site. Revised 12/8/2022 PART 2:TYPE OF REVIEW ❑ Septic System • Age of system • Age of house n I � ^�n y�.0 Number • Number off bedrooms I v s V T\ J 77 • Name of last owner • Is house currently occupied? 0 YES ❑ NO J • If not occupied, how long has it been vacant? ❑ Water System • Number of service connections on the water system? A 0 Lo PA 9-FAi • If a public water system, name of system Iv • WFI number Y 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♦cn1 i5 Its evv fiA"llj ob6tft e'rotc= deso,\ chA bully SFIz 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) st- "es LOT SIZE � -115 X 250 CIS' 5. 32 Acres COMPASS N W c' 365' Applicant's Signature: Date Page 2 of 4 This form may be scanned and available for public view on the Mason County Web site. Revised 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 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 faclllties,madure pile,animal 0 ❑ ❑ 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. (� �m.5 -h�rc�ly foam r�adT�► skrat Soil Conditions Test Hole #1 Test Hole #2 Test Hole#3 w rv%$ I t1`41 lNr`5 -Yt t C I,hI S teJzL+ v+ o W ►z� w� robes +:t Soil Type: Soil Type: Soil Type: 3 r • �� N Restrictive layer. �jZ r.Z Restrictive layer: Restrictive layer:ye /.Slope: D—J Slope: �` Slope: tin' 3 Distance to Shoreline: j 00 T Distance to Shorellne:JDS41 I Distance to Shoreline:P& Page 3 of 4 This form may be scanned and available for public view on the Mason County Web site. Revised 121812022 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 avaI table for public view on the Mason County Web site. 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