HomeMy WebLinkAboutWEL2023-00022 - WEL Application - 4/19/2023 litCiag 7)--e ...,;-:.,,,..,
/ ' , MASON COUNTY
APR 1 9 '2-'2 ' 'a . j' COMMUNITY SERVICES
• i Bu,7ding,Planning,Environmental Health,Community Health
._ -- 415 N 6th Street,Bldg 8,
Shelton WA 98584
Shelton:(360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 v Elma: (360)482-5269 ext 400
FAX:(360)427-7787
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APPLICATION FOR WELL SITE INSPECTION
• Permit Number Payment Information Instructions
WEL Receipt Number 1. Complete Part 1. Incomplete applications will be rejected.
� - 0 Cash 2. Attach a detailed plot plan.
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❑ Check 3. Clearly stake out or flag the well site.
DC°a 4. Submit application and appropriate fee to Mason County
Date of Payment Public Health. Refer to Mason county Environmental Health
Fee schedule for cost.
PART 1: Applicant/Parcel Identification / 1 n
Water System Name y_o\ger i j1/ L.CCU I v�,'S ,, ,,�l,n
Site Address /� N l C4 I u"1 cl .�(Ct_CiL 144 ' (I� Li" `ddi
Applicant bG,./i ci J/0l-e,(S-{-O 6 Phone 25-3-20 S •-/ )/
Mailing Address Q) kC i(C. A�ie-- N q (�
City �'(f C j t-in Y bll State kZip / CJJ3 2-
Parcel Number .-/3 JocO 0 0 2 C 1 �,fi
Directions to Site Z / Q-i So L ri of 1 e Nt �WC ..cl'Ii1/ 1 OY\ TF'\ r) (fi
Water Source is: New 0 Existing System Type: 0 Well 0 Spring No.of Proposed Connections '-'2--
PART 2: Health Department Review(Staff Use Only) wen 4°' fv 2e wain' `0r .
p (,pf 2sy A� folk 9t
YES NO NA kfzr fn3 3�N►c '
�� � io+uff fit/w 1 nostll efy w;fhi►1 PS
,(,y 10 ❑ 0 Evidence of existing sources of contamination wl in 100 f000rad�ius of wa�er'source.
t pm (drainfields, tanks, buildings; indicate distance on plot plan)
0 rg 0 Are there roads within the 100 foot radius of the water source? If so, is road s i : Cgunj�oV
What is distance to ROW? I�(3 /`A'°� ,• {.cOE D
r$ 0 0 Does the ground slope away from the water source site? (show slope on plot plan)
0 0 Z Is the well cap satisfactory? MAY 2 2 2023
0 0 tO Screened and vented? tIENTAL HEALTH
Z] The well casing extends above level ground/con QA ( r ����
vie
❑ ❑ ® D
Is there evidence of a surface seal? t r-44-01l
cal- `��'.4s'9$gy rICRIMPINgt
El 0 TN Does the seal appear adequate? art -I LZ• �fB7-Z7y
— - rp 0 Is a variance necessary for well site approval?
Comments DPst na{cd VA1%I� Offt�s to be Wrfh ?Si Of 5e f%c dra01f ifd on ()ci(t1 ZZ33&SOdOlO3.
Pe/t on rs/77 : 1Ueu leCglion mef✓fc qr t .Se/SO(t refvire~fr
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Pass 0 Fail Inspector Date S( na(N Z)
This form may be scann nd available for public view on the Mason County Web site.
Findings in this review reflect observed conditions as they existed on the day of the site inspection.No claim is made,express or implied of the future
success or failure of this system.Well Site passage does not constitute water system approval.Water system approval is a two part process.
1)Passage of the well site.2)Approval of the water system design.Once the well site is passed the water system design may be submitted for review
J:\EH Forms\DRINKING WATER FORMS\Drinking Water Well Site Inspection App.docx Revised: 1/20/2017
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2 3 is MASON COUN ENVIRONMENTAL HEALTH
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