HomeMy WebLinkAboutCRT2023-00001 - CRT Loan Cert. / EH Review - 4/5/2023 ►
MASON COUNTY 415 N584
SHE TONE360-427-9670, XTT, SHELTON WA 8400
Public Health & Human Services BELFAIR: 360-275-4467, EXT.400
ELMA: 360-482-5269, EXT. 400
FAX: 360-427-7798
I8`7 1
APPLICATION O FOR ENVIRONMENTAL HEALTH REVIE APR 0 5 2023 L
Permit Number Payment Information Type of Review BY:
❑ Septic and Water $430
CRT Receipt Numbera3 ' J(0-L
_❑ Septic $255
❑ Cash
TS Water $255 (Individual and Two Party)
OCheck
O� ❑ Group B WS $95.00 (+$95.00/hour beyond 1 hour)
" ❑ Property Evaluation $350
Date of Payment u t:23' 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 Applicant ell no \ macyc\ % Phone 21 3. 1 - 9'5cl
Mailing Address of Applicant 2'4615 lot A'e S f PT 643
3
City K-e,v+ State WA Zip GI b 0;2
12-digit Tax Parcel No. - i 90 - - 00,00
Site Address /90 S E C ryS- t Cy k C f j S he I-ton, w A 985614
Brief Legal Description PLL 1 OF 1`3 L A *06 S Z P T N T R 1
OF S 1s/Io / S uq /, 0G
Driving Directions Gc.A - 1E_ or rook "SE Ac\A � \\
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Turn I e F on+c road. "s c-rIs+c t GrK Ct
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This form may be scanned and available for public view on the Mason County Web site.
rs vies v.e� _ Av,� 4) l C�t�.Nel ��1Rev6yed 12/8/2022
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6&Si?/vf\.VO+-- Y® to c -f & 6v\ Pc& C2 ( 31 c18�{ — 000(D3
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?
2
Water System 'i ./r. G,re e V. .#2 i,,); li b.eca V �
o' Z— 4
• Number of service connections on the water system? 1 Y1O ) --- `1
•
• 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 review.
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)
LOT SIZE
.5- je___ (1-14-04---4-6( x
• re ��\e
i
�L c:c s >,-1e-A s i 5. 02- Acres
-- ,,X \- is r e ( COMPASS
. cep r o ;c. Vv. 6,--) d,.,v e'v (1/ks 54
(c.r,ocke1/4\ Gc k 10.P�l�Q Q -4-0k--) .kt S tt< So✓.-1-h., eAs.l- /
Applicant's Signature...__,g _(,,,....----- _,>7
Date 3/ Li / 3
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.
C The site was inspected and the system location appears to be consistent with recorded documents.
C 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.
C 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 12/8/2022
•
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? I 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.
Revised 12/8/2022