HomeMy WebLinkAboutCRT2026-00004 - CRT Application - 8/20/2026 415 N 6TH STREET, SHELTON WA 98584
, MASON COUNTY 1 SHELTON.360-427-9670, EXT.400
COMMUNITY SERVICES BELF 360-482-5269 EXT. 400
ELMAMA: 360-482-5269, EXT.400
Building.4lanniny.Environmental NealOi.Community HeaI1M1
FAX'. 360A27-7798
APPLICATION FOR ENVIRONMENTAL HEALTH REVIEW
Permit Number Payment Information Type of Review
�_ Septic and Water $405
CRT Receipt Number —&,,L;u $240 .
.T Cash -p31453 Water $240 (Individual and Two Party)
�} Check Group B WS$90.00 (+$90.00/hour beyond 1 hour)
Date of Payment o3"fcYb/1'e OC Property Evaluation $335
Resample $30 tab 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 Gerardo Armengol Phone 206-673-1248
Mailing Address of Applicant 5930 164th PI Sw
City Lynnwood StateWA Zip 98037
12-digit Tax Parcel No. 320215804007
Site Address Vacant lot on Hillcrest st t uo e*-jiLCh fi
Brief Legal Description SHORECREST BEACH ESTATES #1 BLIC 4 LOT 7
Take E Agate Rd/ E Crestview Dr and turn left at E Hillcrest dr
Driving Directions
AUG 0
Page I of4
This form may be scanned and available for public view on the Mason County Web Site.
Revised I"
NORTH ARROW
125 FT
---------- ---- --- --- - --- -- -- - -- --- --- ----- --+ I
(TH-2) (TH-3) I E
(TH-1) I H
I
L
j
65 FT C
CIE
Is
T
Z-5 qk R
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?
Water System
• Number of service connections on the water system?
• If a public water system, name of system
• WFI number
f 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.
Feasibility evaluation for a proposed single-family residence (stick-built or manufactured home).
Requesting formal county soil log evaluation to determine site suitability, seasonal water table levels,
and permissible septic system types.
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
65 X 125
19 Acres
.g cd4tirkz.Q COMPASS
iN
gerardo 4naeugol 2026-08-04
Applicants Signature. Date
Page 2of4
This form may be scanned and available for public view on the Mason County Web site.
Revisal 1.2'I tl
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
n 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?
H G' 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
j 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.
L. Department files contain water system design and letter of approval.
ooIrft c
Soil Conditions
Test Hole #1 Test Hole #2 Test Hole #3
Csarwl Flo t al.oly I oars rl &T7>
Soil Type: Soil Type: H Soil Type: II I Oa lM
Restrictive layer: 1// 1I' Restrictive layer:
'i_-c)
Restrictive layer: l9 hVCt
Slope: N b L Slope: L /. ( Slope: �Z__
Distance to Shoreline: W T Distance to Shoreline: T Distance to Shoreline'.
1'age 3 of4
This form may be scanned and available for public view on the Mason County Web site.
Reviacd 1/2:I4
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
I. system has been in use on a regular basis for the last 6 months.)
Sanitary survey? -1 Pass (_i Fail _ Suspect -i 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
L regulations.
I Well Construction Permit ❑ Pass I Fail
PART 6: Comments
(�LQet" m1 J21A; c-0 \ (t4
1 -\lCVv onst+ec1;c Sys—
Z`` A- soil
Inspector QCJTLI_*4r\IQ l 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.
P� �aSe Gill al
(s( t) 97i1 -g670
Page 4 of 4
This form may be scanned and available for public view on the Mason County Web site.
Revfscd 1/2,18