HomeMy WebLinkAboutWEL2005-00064 - WEL Application 713. -EE-2005 OS:7,6 FF7f:COUNTRY IN5LR PjCE 3503579064 TO:360,1620056 P.CC3
MASON COUNTY MASON CO .
DEPARTMENT OF HEALTH SERVICES
429 W CEDAR Sr, PO BOX 1666, SHELI ON WA 98584
SHELTON (360)427-9670 ELMA (36C)482-5269 BELFAIR (350)275.4487
WEE htt01/www co.mason.wa us FAX (360)427-7796
APPLICATION FOR WELL SITE INSPECTION
a.J Receipt Numbe Q WE dC.)0S-t/(_�r40Lr
/005 1. Complete Part 1. Incomplete applications will not be accepted
�A_ _ 2, Attach a detailed plot plan and vclnity map
�tbflleatbat ViRy 3. Clearly stake cut or flag the well site
4. Submit application and appropriate'ee(s)to the Mason County Health Deot.
PART 1: Applicant 1 Parcel ! entification /J
Water System Name (rl , y/TY) !(. AS,r. (.14Lu4,--
/
Site Address
Applicant �/ , ((i pc. w 4 Phone Y-2I—
p — Issy ,z
Mailirg Address Po) gdu (
City 24 / n State Zip ell r0-
Parcel Number /d(' ,,2-( (( 00006.1
Directions to Site L u/ 1 61 A 7107,1 £ _, • s��`
(,, Lir 729u /U
Water Source is: El New ❑ Existing Number of r3
System Type: a Well ] Spring Proposed Connections K
. via
PART 2: Health Department Review (Staff Use Only)
YES NO NA
LI 71 ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(dralnfields, tanks, buildings; indicate distance on plot plan)
❑ .K ❑ Are there roads with n the 100 foot radius of the water source?If so, is road private, County cr State.
What is distance to ROW?
❑ ❑ n, Does the ground slope away from the water source site?(show slope on plot plan)
[] ❑ ❑ Is the well cap satisfactory?
❑ ❑ 0 Screened and vented?
❑ The well casing extends above 'eve)ground/concrete slab?(circle one)
❑ ❑ E Is there evdence of a surface seal?
❑ ❑ ❑ Does the seal appear adequate?
❑ �1 ] Is a variance necessary for well site approval?
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