HomeMy WebLinkAboutWELl2005-00112 see new TPN - WEL Application - 1/5/2006 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584
SHELTON (360)427-9670 ELMA (360)482-5269 BELFAIR (360) 275-4467
WEB hfu://www.co.mason.wa.us FAX (360)427-7798
APPLICATION FOR WELL SITE INSPECTION r�l�
Receipt Number: �—Q— J - WEL: DCVO co
1. Complete Part 1. Incomplete applications will not be accepted
2. Attach a detailed plot plan and vicinity map
Date Received 3. Clearly stake out or flag the well site
4. Submit application and appropriate fee(s)to the Mason County ealth Dept.
PART 1:Applicant/Parcel Identification
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Water System Name
Site Address DA)
Applicant HT/d C•Ve-S 1 IC Phone �2 z
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Mailing Address
City State Zip �p
Parcel Num v
Directions to Site L
mt /� ✓ G '�'!Z ✓r
Water Source is: New rs"a�0/9tis�p
El Existing / Number of �j_ , „p i
System Type: ❑ Well ❑ Spring Proposed Connections
PART 2: Health Department Review(Staff Use Only)
YES NO NA
❑ Evidence of existing sources of contamination within 100 foot radius of water source
(drainfields, tanks, buildings; indicate distance on plot plan)
❑ �❑ Are there roads within the 100 foot radius of the water source? If so, is road private, County or State.
—� What is distance to ROW?
FJ ❑ ❑ D as the ground slope away from the water source site? (show slope on plot plan)
❑ ❑ Is.the well cap satisfactory?
❑ ❑ E reened and vented?
The well casing extends above level ground/concrete slab? (c rcle one)
❑ ❑ � there evidence of a surface seal?
El Does the seal appear adequate?
❑ ❑ Is a variance necessary for well site approval?
Comments
G'
ass Fail Inspector Date
Koi-ng4ind determinations of this review reflect observed conditions as they exis 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 wnstimte water system approval.Water system approval is a two part process. 1)Passage of the well site.2)Approv I of the water system
design.Once the well site is passed the waters stem design may be submitted for review