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Home My WebLink AboutWEL2008-0064 - WEL Application - 10/16/2008 426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584 SHELTON (360)427-9670 ELMA (360)482-5269 BELFAIR (360)275.4467 WEB __ FAX (360)427-7798 APPLICATION FOR WELL SITE INSPECTION Receipt Number: 5 15'ZD/)A — WEL: 0 , �� y Q C T 16 Z00 5. Complete Part 1. Incomplete applications will not be accepted n me RIO Received 7. Clearly stake out or flag the well s e S. Submit application and appropriate feels)to the Mason County Health Dept. PART 1:Applicant/Parcel identification Water System Name ( lx r k / J /1 Site Address � �O L �5 .'1 )N•0 /SILalf Applicant r t -i- e r ! r Phone yl ^ 23sl Mailing Address City SQG//oil State W. Zip �gY Parcel Number l' .c ;2- 9oo/.I / Directions to Site Y/l1 i m/f 111AS6s1 M a'n I'itl/� � Water Source is: ew ❑ Existing Number of 2 System Type: ell ❑ Spring Proposed Connections PART 2:Health Department Review(Staff Use Only) YES NO NA ❑ ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfieids, tanks, buildings; indicate distance on plot plan) ❑ ❑ ❑ Are then: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) ❑ nx Is the well tap satisfactory? Cl ❑ u 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 ariance ne ary for well site approval? Comments W I r p Pass Fail Ins ctor - Date Fiadiag determ' tlria mview rdleot ab u ey day the site inspection.No olaim' .express or plied of the futures s me of"ayatm. Walt Site passage does not oomtitule water system approval.Water cyst®approval is a two part process.1)Passage of the well site.2)Approval of the water system design.Once the well site is passed die systems design may be submitted for review MASON COUNTY PUBLIC HEALTH - - - PO BOX 1666 SNELTON,WA 98584 APPLICATION FOR RE-INSPECTION SHEL FAX (360)427-9670 FAX (360)427-8442 - DRINKING WATER PROGRAM - ELMA (360)482-5269 BELFAIR (360)275-4467 DIRECTIONS: 1. Complete parts 1 through 3 and submit to the Drinking Water pro m at the address indicated above. The fee of$110.00 must be submitted with the application. 2. Staff will perform the re-inspection within two weeks of receipt of application and make a determination, which will be reported in Part 4 of this application. 3. Staff findings may be appealed in accordance with Mason County Code Title 15. PART 1: REQUEST FOR RE-INSPECT Applicant's Name Mailing Address Telephone: (4b Assessor's Parcel Number 3 _�2 ? C - 2 f— - G G Detailed Directions to Site: 0 l Reason for Re-inspection: ,�� ..73 S ❑ Changed well site,area from previous inspection Directed by staff to re-apply ❑ Other(please specify) PART 2: AUTHORIZATION Applicant C iC'� t� Date /7 JAWater program\FORMSDW Revised 01-9-2008 PART 3: PLOT PLAN Use this space to draw a detailed plot plan,or attach one to this application. The plan must show the precise location of the well(existing or proposed),dimensions of the property,existing and proposed septic system(s) on the lot or within 100 feet of the proposed well on adjacent lot(s), location of access roads, location of structures and any other pertinent items such as rivers, lakes and wetlands. PART 4: RE-INS ECTI N DETERMINA,TION: .,e&*-1 R vo Environme tal Health Specialist I D to Mwater p gr ORMSDI� l/ _ Revised 01-9-2008 qj CA- Z il i� r � I s I . I e rE� � c Lo Y i �- `� n LC 7i� s