HomeMy WebLinkAboutWEC2021-00053 - WEC Application - 8/17/2021 4"14y MASON COUNTY
` ; COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health
415 N 6th Street, Bldg 8,
Shelton WA 98584
Shelton:(360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 ❖ Elma: (360)482-5269 ext 400
FAX: (360)427-7787
APPLICATION FOR WELL SITE INSPECTION
...................
Permit Number Payment Information Instructions
WEL Receipt Number at -4 b 1. Complete Part 1. Incomplete applications will be rejected.
0ba 1 0 Cash 2. Attach a detailed plot plan.
.5} Check
v 3. Clearly stake out or flag the well site.
RR 4. Submit application and appropriate fee to Mason County
� Public Health. Refer to Mason county Environmental Health
Date of Payment in lob( Fee schedule for cost.
PART 1: Applicant/Parcel Identification
Water System Name }f)MIX ll��ll
Site Address peo-i 11 �
Applicant /V `1 )4- -0C4\11. S Phone
Mailing Address � ( DelvIS Yyv\
City - Frzt( t . State Wfr Zip c''ec
Parcel Number 320 t.D3 ► Oa() ( p Directions to Site -a`[..e G+.e on r qol L ®a►'IIC��S
4.ey ))i j j< YacJ4 u J vVl cxn ke-e- 5 i 10 • ( 1n -10 Lee+.
Water Source is` New ❑ Existing System Type: NI Well ❑ Spring No. of Proposed Connections -b
PART 2: Health Department Review(Staff Use Only) S
YES NO NA (b
❑ ❑ ❑ 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 road private, County or State. —1—
What is distance to ROW?
❑ ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
❑ ❑ 0 Is the well cap satisfactory?
❑ ❑ ❑ Screened and vented?
❑ The well casing extends above level ground/concrete slab? (circle one) 3 4
❑ ❑ ❑ Is there evidence of a surface seal?
❑ ❑ ❑ Does the seal appear adequate? r)
❑ ❑ ❑ Is a variance necessary for well site approval? A
r C V�
Comments )(,r s p��rej V'
❑ Pass 0 Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site.
1t inge* 1 ▪ efIect tab erved•.conditions as'they+a i tat the day of the sits ii�ciion f.+lo,claim `rrl ,e res0 (r '3 ta�t t11f0tua
l3 ire is system Wit Site passage does not constitute water system approval.Water system ap o4al t
N:4—" a. t▪v alte.2)Approval of the water system design.Once the well site is Pitsed the water" tem t "rrl ,> "du rrllt d:fOr is nr
J:\EH Forms\DRINKING WATER FORMS\Drinking Water Well Site Inspection App.docx Revised: 1/20/2017