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Home My WebLink AboutLRG2021-00002 - LRG Application - 7/12/2021 L i nZcc,_cp tzanrize,, Yer Lev- Co y8- .l5`/ 7-ir".4T T `'^� MASON COUNTY NTY 415 N 6TH STREET, SHELTON WA 98584 SHELTON:360-427-9670, EXT.400 l I x COMMUNITY SERVICES BELFAIR:360-275-4467,EXT.400 ELMA:360-482-5269, EXT.400 Building,Planning,Environmental Health,Community Health FAX:360-427-7798 APPLICATION FOR LAND USE EVALUATION Amount Paid: RECEIVED Receipt Number: JUL 1 2 2021 Instructions 615 W. Alder StrE et 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-foot 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 identified test holes must match the locations shown on the proposed plot map. PART 1 : APPLICANT/PARCEL IDENTIFICATION It:k4i Jul' Large Lot Subdivision O Subdivision 3ce0 `7(6 `'t i O Short Subdivision 1 ❑ BLA Name of Applicant {(1.0h C—onk Phone 360) - 4912 Mailing Address of Applicant 159 I W lolly -taut( City Ma-f-(oc . State WA Zip `j85( o 12-digit Tax Parcel No. 6,Z I21 -12— o Property Legal Description nm(,t/ %4 ,6,44-4.4. itje- P4 '55z.., -41 ,T ZIAJ l R 4kJ Lot Sizes (Acres or Square Feet 3 5-pc, 5 RC._ LOT 1 LOT 2 LOT 3 LOT 4 LOT 5 Directions to Site Mkt $‘,‘1_,l-Vert \.td-{�(� �{e /�,� 1-fury► t (9471— o h l&I 13eu/i iI� Z‘.1 e Glow +0 kl bee v;a Lzzp eci t- lc e_ 1 e 1. 5 y 0---k W Bee vt bk Loop t2c1 --a \.1 K4.U1 t-k i2ci. E'a 1I aw I e,Gl y gliji24 -1, 15 / . PART 2: INTENDED USE OF PARCEL Intended Use of Property(Check One): -8--'Single Family Residence Multi-Family Residence Li Other, Specify Water Source for Parcels(Check One): 4 Individual Wells ❑ Community Well(Public Water System) This form may be scanned and available for public view on the Mason County Web site. Revised 3/2/2017 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 A 0. 3(e —3(c. Depth of Mottling Depth of Mottling Depth of Mottling Depth of Mottling Depth to Rest. Layer Depth to R est. Layer Depth to Rest. Layer Depth to Rest. Layer 'J Soil Type (USDA) Soil Type (USDA) Soil Type (USDA) Soil Type (USDA) Test Pit B Test Pit 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? (Y/N) Shoreline? (Y/N) Shoreline? (Y/N) 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 the Mason County Web site. 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(450 gallons per day). COMMENTS 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(s): n 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 (s) required prior to approval have been met by the applicant Health Official Date PART 5: REVIEWER SIGNATURE Health Official Date This form may be scanned and available for public view on the Mason County Web site. Revised 3/2/2017