HomeMy WebLinkAboutWEL2011-00032 - WEL Application - 11/15/2011 SON COLT"V
Public Health
Always working for a safer healthier Mason County
PO Box 1666,415 N 6"Street, Bldg 8,Shelton WA 98584
Shelton: (360)427-9670 ext 400 -:• Belfatr:(360)275-4467 ext 400 ❖ Elms:(360)482-5269 ext 400
FAX(360)427-7787
APPLICATION FOR WELL SITE INSPECTION
Permit Number Payment Information Instructions
WEL �c t ` Receipt Number C 1. Complete Part 1. Incomplete applications will be rejected.
❑ Cash 2. Attach a detailed plot plan
❑ Check
b v Q 3. Clearly stake out or flag the well site
Date of Payment 4. Submit application and appropriate fee(s), ($155.00 Fee)to
Mason County Public Health.
PART 1:Applicant/Parcel Identification
Water System Name SS U
Site Address SSo 6 A4c o le- �.e Ir ' e /.rl .�
Applicant Cyr/ t Phone mac) -6sU -6 3rs—
Mailing Address 2/Z3 2- / AJe: S
City &S NO -,e..J State Zip /y
Parcel Number -L10 7-6 - (O ^o`(BOBS la J�r-d�
Directions to Site S S1a�-t .K /C 1,4 - J 4"e co To /uc a le, �—
NreA /t' T s5 r &-!z Co4P - `t060
Water Source is: ❑ New (X Existing System Type:,Well ❑ Spring No. of Proposed Connections z
PART 2: Health Department Review(Staff Use Only)
YES NO NA
❑ Q�, ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drai*lds,tanks, buildings; indicate distance on plot plan)
®' El ❑ Are there roads within the 100 foot radius of the water source? If so, is road dvate�Ccunty or State.
/ What is distance to ROW?
], ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan)
❑ ❑ Is the well cap satisfactory?
❑ ❑ Screened and vented?
❑ The well casing extends I�% i v kC 6L;S above level ground/concrete slab?(circle one)
❑ ❑ ❑ Is there evidence of a surface seal?
❑ ❑ ❑ Does the seal appear adequate?
❑ ❑ Is a variance necessary for well site approval?
Coro ents
Pass ❑ Fail Inspector Date I1
(((Findings In this review reflect observed conditions as they existed on the day of the site inspedlon.No claim is made,express or t 1plied of the future
success or fallure of this system.Well Site passage does not constitute water system approval.Water system approval is a two palprocess.
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 31,bmitted for review