HomeMy WebLinkAboutWEL2023-00046 - WEL Application - 8/21/2023 MASON COUNTY r�
y .� . SERVICES
COMMUNITY I111
Building,Planning,Environmental Health,Community Health AUG 21 26e
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415 N 6Th Street, Bldg 8,
Shelton WA 98584 By 6.7
Shelton: (360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 ❖ Elma: (360)482-6169 eXt400 •
FAX: (360)427-7787
APPLICATION FOR WELL SITE INSPECTION
Permit Number Payment Information Instructions
Wo na Receipt Number _ 1. Complete Part 1. Incomplete applications will be rejected.
❑ Cash 2. Attach a detailed plot plan.
e�q�� ❑ Check 3. Clearly stake out or flag the well site.
4. Submit application and appropriate fee to Mason County
Date of Payment Public Health. Refer to Mason county Environmental Health
Fee schedule for cost.
PART 1:Applicant I Parcel Identification
Water System Name North Shore Utility Group B Water System
Site Address 31 NE Oyster Ridge Dr.
Applicant North Shore Utility Water System Phone 360-275-4233
Mailing Address 401 2nd St NE
City Auburn State WA Zip 98002
Parcel Number 32226-34-00090
Directions to Site From WA-3 head Southwest on WA-300 continue on to NE North Shore RD for 8.7 miles
Turn right on NE Oyster Ridge Dr, and pump house will be on the left
Water Source is: ❑ New ® Existing System Type: ® Well ❑ Spring No. of Proposed Connections 4
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 of radiimof the nter source? If so, is road private, County or State.
What is distance to ROW? ( ii1 Gu`�
F ❑ ❑ Does the ground slope away f om the water ource site? (show slope on plot plan)
[ ❑ ❑ Is the well cap satisfactory?
❑ Ill ❑ Screened and vented? 1/
❑ The well casing extends above level ground/concrete slab? ircle one)
❑ ❑ Is there evidence of a surface seal? Cc.),"/C-r-16--se- p/4-
❑ ❑ Does the seal appear adequate?
❑ El Is a variance necessary for wel site approval?
Com ents (eztve, CO(/ep+-iv-c-erke dA/ (,✓.e 1(
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)‹Pass Fail Inspector t Date
l - Web site.
This form may be sca n•� � available for public view on the Mason County
Findings in this review reflect observed co itlo , • •Is existed on the day of the site Inspection.No claim is made,express or implied of the future
success or failure of this system.Well S' assage does not constitute water system approval.Water system 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 the water system design may be submitted for review
J:\EH Forms\DRINKING WATER FORMS\Drinking Water Well Site Inspection App.docx Revised: 1/20/2017