HomeMy WebLinkAboutWEL2007-00093 - WEL Application - 9/28/2007 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 http7//WWW.CO.mason.wa.us FAX (360)427-8442
APPLICATION FOR WELL SITE INSPECTION
RECEIVED Receipt Number: 442007^ 17yj WEL:
S EP 2 S 2007 jj jComete Part 1. Inoom late applications will not be accepted($125.00 Fee)
p
c Nl AL 4. Submit application and appropriate feels)to the Mason County Health Dept.
PART 1:Applicant I Parcel Iderruncation
Water System Name d^fit°/1 le// / y/
Site Address
Applicant /���C � 1� /�, ICJ LL C Phone
Mailing Address
CityJ. �fOy State Zip 9�3Sy
;a ,
f
Parcel Number A/ � J
Directions to Site /)�r/ S�Vr-e re•�/ / ��n /-L���y�i' f�
A.
Water Source is: New ❑ Ebsting Number of
System Type: IV Well ❑ Spring Proposed Connections
PART 2:Health Department Review(Staff Use Oniy)
YES NO NA
❑ X ❑ Evidence of existing sources of contamination within 100 foot radius of water source? V,✓�C S
(drainfields,tanks,buildings;indicate distance on plot plan)
El ❑ Are there roads within the 100 foot radius of the water source? If so,is road privat ou or State.
What is distance to ROW? -ql r
[I ❑ Does the ground slope away from the water source site?(show slope on plot plan)
Is the well cap satisfactory?
❑ ❑ /
Screened and vented? t
. / ❑ The well casing extends abo a grou concrete slab?(circle one)
❑ ❑ Is there evidence of a surface seal?
E]❑ Does the seal appear adequate?
Is a variance necessary for well site approval?
Comments
Pass Fail I r Date
F' ' and determinatiore ofthir review reflecUebserved conditions as they n the day of the sice 1115pacaaa No claim is aw cqrmwor impim of the
success or l8ilme of this system.
Well Site passage does not constitute water system aPpoval.Water system approval is a two fart poceas.t)Passage of the well site.2)Approval of the water
des' Once the well site is the water des' be submitted for review
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