HomeMy WebLinkAboutWEL2008-00064 - WEL Application - 8/10/2009 MASON COUNTY
PUBLIC HEALTH I
426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584
SHELTON (360)427-9670 ELMA (360)482-5269 BELFAIR (360) 275-4467
WEB http://www.co.mason.wa.us FAX (360)427-8442
APPLICATION FOR REVIEW OF A TWO-PARTY WATER SYSTEM
RECEIVED Receipt Number: 0-2 3 7�/ WEL 20 OP-
Attach to existing case
NOV 0 3 ?008 5. Complete Part 1, ($75.00 Fee). Incomplete applications will be ejected.
Date Received 6. Make sure all required documents have been submitted (i.e. well log, water
MASON COUNTY sample and recorded documents)
7. Submit application and appropriate fee(s) to the Mason County Health Dept.
PART 1: Applicant/ Parcel Identification
Water System Name q�{
Site Address 6 a� �t/lg S4'V
Applicant 7F—F y Q 6l,*I k Phone me Ad ,S-Z7V
Mailing Address _--5
City fhp Z7ex/ State «.1*19 zip
Parcel Number Zq) 3,6 _'�2�2' ft Bz-
Directions to Site
PART 2: Health Department Review (Staff Use Only)
l F� NO NA
❑ ❑ Water Well Report with adequate pump test on file?
If no, date of capacity test Driller GPM �P
El ElReceived Satisfactory Bacteriological Analysis? Date of test:
❑ ❑ Received Signed, Notarized, and recorded Agreement or Notice?
❑ ❑ System appears adequate to serve two single-family residences based on information provided?
System Approve System Denied
COMMENTS:
D (7
Sani 'an s Signature D to