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HomeMy WebLinkAboutWEL2008-00034 - WEL Application - 5/22/2008 MASON COUNTY DEPARTMENT OF HEALTH SERVICES Al 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)427-7798 APP I SITE INSPECTION Receipt Number: 1 L- WECL O,6 '37 MAY 2 " LUU$ 1 Complete Part 1, incomplete applications will not be accepted($125.00 Fee) ENV:, ,. ,�,. _ DatHffideNdd 3 �' 4 5ubm-aapplicationPndappropWatefee(s)to the Mason County Health Dept. PART 1: Applicant 1 Parcel Identification Water System Name Paradise Water System#1 Site Address McEwan Prairie Jr 1-A) Applicant Nathan Stout Phone 360-490-3198 Mailing Address PO Box 2371 City Shelton State WA Zip 98584 Parcel Number 321334090021 From Shelton travel out on Brockdale Rd. Turn right on McEwan Prairie Rd. Look for site on left Direction to Site just before Mason Lake Rd. See attached map on back Water Source is: ® New ❑ Existing Number of System Type: ®Well ❑ Spring Proposed 2 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 the 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) ❑ ❑ ❑ Is the well cap satisfactory? ❑ ❑ ❑ 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? ❑ ❑ ❑ Is a variance necessary for well site/approval? /J / / / Comments�, S �l -� fi/(�tt '� ll' AI TG, ,✓/ S776a-r. /t-27fce<.r�t sv Pass Fail Inspector Date Finding and determination of this review reflect observed condition as they existgon 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 constitute water system approval.Water system approval is a two party process.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 submitted for review. �€J. 0 5 I of Cbvt a wl/i.�a o ie/J✓! / pyl �✓©Q%�f� /lav B-" ,4ei l"G 4ow i ✓I /d-r t/ rr)n/Y WI a XS � !/��