HomeMy WebLinkAboutWEL2001-00020 - WEL Application - 5/7/2001 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES -
Environmental Health Water Quality erso
APPLICATION FOR WELL SITE INSPECTION '
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Receipt#
Dat �y Received By Tidemark#WEL Z�
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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 property,the
location of all existing septic systems within 100 ft.of the well,and the location of any structures on the property.
2. Clearly stake out or flag the well site.
3. Submit the completed application and fee to the Health Department,POB 1666 Shelton,WA 98584
APPLICANT/PARCEL IDENTIFICATION W
WATER SYSTEM NAME ce"rH G 4
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OWNER NAME�Lc" c I a r bps C2�uNc '� Zd v �� �7,` TELEPHONE tU5 1 - 7���
APPLICANT NAME / TELEPHONED( ) -
SITENVATER SYSTEM ADDRESS
i i�!'� So�r`ti �t rye ��o
MAILING ADDRESS
ASSESSOR'S PARCEL NUMBER_0 �� ®— SG O O O CITY
STATE ZIP
SUBDIVISION (IFAPPLICABLE) DIV BLK LOT
DIRECTIONS FOR LOCATING SITE:
Ir CA
ka� LLVI INITY SKETCH
�9
19 y
• WATER SOURCE IS:_NEW OR_EXISTING;_WELL OR _SPRING NUMBER OF PROPOSED CONNECTIONS
• Update:December 18, 1997
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