HomeMy WebLinkAboutWEL2008-00035 - WEL Application - 5/22/2008 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.wa.us FAX(360)427-7798
APPLICATION FOR WELL SITE INSPECTION
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r 7 (7 I Vq� E Receipt Number:6, i�ZPQISJ
MAY 2 2 2008D 1 Complete Part 1 incomplete applications will not be accepted($125.00 Fee)
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H' ALTH 4 !p9pimels)mason Mason County Health Dept.
PART 1: Applicant 1 Parcel Identification
Water System Name Paradise Water System#2
Site Address McEwan Prairie (Tr 1-D)
Applicant Nathan Stout Phone 360-490-3198
Mailing Address PO Box 2371
City Shelton State WA Zip 98584
Parcel Number 321334090024
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?
Comments_Ak SAGO C X/ — 7T<Et 'z
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Pass F it Ins ector Date O�
Finding and determination of this review reflect observed condition as they ex d 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 constitute water system approval.Water system approval is a two party process. I)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. L
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