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HomeMy WebLinkAboutWEL2007-00012 - WEL Application - 1/26/2007 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 http//www.co.mason.wam FAX (360)427-7798 mm���� APPLICATION FOR WELL SITE INSPECTION RECEIVED Receipt Number: 6!62 bj l5�j WEL: n �2 AN 2 ('j fttr' 1. Com fete Part 1. Incom lete applications will not be accepted($125.00 Fee) t Date Received t �a EALTH SERVICES, EFi 4. Submit application and appropriate fee(s)to the Mason County Health Dept. PART 1: Applicant/ Parcel Identification Water System Name: D K Water System - Site Address Mason Lake Drive Lot 3 Shelton, WA Applicant Richard Dickinson Phone 360.520.7378 Mailing Address 6321 Nevion Drive SW City Olympia State WA Zip 98512 Parcel Number 321331090013 Directions to Site From Shelton travel north on Hwy 3 and turn left on Mason Lake Rd look for site on right with Arcadia Drilling Sign after McEwan Prairie Rd Right after new Hi-Line Home. Water Source is: x New ❑ Existing Number of System Type: x Well ❑ Spring Proposed Connections 2 PART 2: Health Department Review(Staff Use Only) YES NO NA ❑ �?j ❑ 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? ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) ❑ ❑ Irk Is the well cap satisfactory? ❑ ❑ I Screened and vented? The well casing extends above level ground /concrete slab? (circle one) ❑ ❑ Is there evidence of a surface seal? ❑ ❑ Does the seal appear adequate? ❑ �L Is a variance necessary for well site approval? Comments r 07 Fail ass finding nd detervtinations o`this review reflect observed condt ions as they existed the day of the site inspection.No claim is made,express or implied of the (u ccess or failure of th s system. We Site passage does not cc nstimte water system approval.Water system approval is a two part process. 1)passage of the well site.2)Approval of the water stem design.Once the well site is passed the waters stem design mybe submitted for review RPR-12-2006(WI.-D) 13; 06 Ma, County Title Insurance (FR' �60a260716 P. 006/006 . s+�zz,�a s1aoRr PEA r I I, �Z— s7roarSu80/Hsronr Gp -- - _ DA AP OI 1, ✓RUES A. & SHIRLEY SR/X, JOIN A. & ne .cl� JEAN 615HOP, PAUL E. & dl.YTNE E. REID ,Nre,�� 1wAC714or ze z!� 612 22 SE 770N is TOWSH7P .21 NORM RANGE* -T AESr, WM. 33 34 JJJD KITSAP WAY FOUND NNgETE MONUMENT Put J 9REl=Any, WA. 01=0S&T VOLUME If PAOC 1TB C IPARCR A'4 7Tt]J 70.Op0/0 OF 9URVE17 N rr L o �I T: y ee � C S i � � /.�aE9•.•' •N / s � C7 Tf .. e eeOdfl" W / ,emu• abOD Fc=eLE +/ff :• I }xc1 i Y o ESL {I IUD, R yro^'i 5D' rn s� bl u 11 l RL.z / MORAN G 1.43 AOTCC•• ^� ' / q�7071'S6' Q d T R.777.D4' b s p 3 r S SD•-.� 27.7D' �� / 1,M A ES '.. fO'-4 ROO. uNC % ;� N 1D1a10 E ' �1 DU: I FOUNb mum" 1 ,et AD'7e• ' T 1WBOi Cn p R+727.Df ZY1 MDNWENY POI L N 75 - _N "OLUME 14 PAOC'173 4 fig' 1�• a'svaee+s 4TDF.1! �'• , \' POLE I R.ii1.0xx . L•1D7.00' 1 � PC Cy 2e M •�'� w I ' �,1 iD7 a 11 S a.773.Nf' ii ACM g BLS Vf07.LIT \ 1 1 x ••• 1 i 1.43 - 9D.eD r N unrlD' \ 36.34" FOUND CONNING A,MOTCO ��Np 9Mhn h MERIDIAN T4 y PL iulll W BASED ON MASON LAKE ROAD C,TE ® m uo mom ROAD PROJECT CONCR r �• MONu114VT PER NUMBER 100E T� P OC 178 FOREST LAND SURVEYS 1Frr� or suavErs - $ �9RICHARD 8. NORRIS P.LS. Locw�ec� -qe Lc+S 3 Su v i TLVw h j WPM T1 � Oo SIt+FP�.� 47r.V�u w •- 9' J t`l w . LA �' w N l � er S©`(