HomeMy WebLinkAboutWEL95-0017 - WEL Application - 2/24/1995 MASON COUNTY
FF9 2 4 1995
DEPARTMENT OIL HEALTH SERVICES -
Environmental Heath Water QuafI=AITIPersonal will,
APPLICATION FOR WELL SITE INSPECTION
Receipt#_(13c Date -��eceived By�_Tidemark#WEL9 5
INSTRUCTIONS
1. Provide a location sketch and a detailed plot plan. The location sketch should be detailed sufficiently so that a field inspector
can easily find the site. The detailed plot plan shall show the precise location of the well,dimensions of the pr the
location of all existing septic systems within 100 ft.of the well,and the location of any structures on the
2. Clearly stake out or flag the well site.
3. Complete this application form and submit with the$75.00 fee to the Health Department.
APPLICANT/PARCEL IDENTIFICATION
WATER SYSTEM NAME
OWNER NAM TELEPHONE 10 �37�
APPLICANTNAME T)MI t IV (2 TELEPHONE(3�)22 S3 /W
SITENVATER SYSTEM ADDRESS l``v I_ 2 C) I�� C 2 FA )q�
MAILING ADDRESS 9 0 O t+� AP D V L15 RD C�
STATE ZIP 7�
CI
ASSESSOR'S PARCEL NUMBER 2— 2- 3— t 1-7`— 0 3 i eTY
SUBDIVISION (IFAPPUCABLE) DN BLK L T
DIRECTIONS FOR LOCATING SITE:
VICINITY SKETCH
C1 j J
WATER SOURCE IS:_NEW OR_EXISTING;_WELL OR _SPRING NUMBER OF PROPOSE CONNECTIONS
WWDATAWACHIVE\WELLSITE.FM3 Update:Dmmber5,1994
Well Name
Applicant Name
Parcel#
Tidemark# WEL9_
HEALTH DEPARTMENT FINDINGS
YES ` NO N/A
❑ yb ❑ There is evidence of existing sources of contamination with the 100 foot radius of the Nell.
Indicate distances on plot plan
❑ ❑ Roads within the 100 foot radius of the well are ditched or drained so that surface run-off is
conducted away from the source.
❑ ❑ The ground slopes away from the source site.show slope on site plan
❑ ❑ The sanitary seal on the well cap appears satisfactory.
❑ ❑ There is a substantial concrete slab poureq around the well casing.
❑ Cl " The well casing extends above ground levellconcrete slab.circle(ne
❑ ❑ Variances will be necessary for well site approval.
WELL SITE PASSED WELL SITE NOT PASSED ❑
HEALTH DEPARTMENT COMMENTS
Fuutings and determinations of this review reflect observed conditions as they existed on the day the e valuation was
performed. No claim is made by this office, either expressed or implied, concerning future success or failure of the
system and site evaluated.
Well site passage does not constitute water system approval Water system approval is dependant upon a tH ollartPrOcess
1)passage of the well site,2)Appoval of the water systan design.Once the well site is passed water gvan Design maybe
submitted for review.
REVIEWER SIGNATURE —DATE a
REVIEWER PRINTED NAME
lJAWDATAWiClUVE\WELISrFE.FM3 Update: fix*5,1994