HomeMy WebLinkAboutWEL2023-00050 - WEL Application, Design, Letter - 9/27/2023 Shelton. (360)427-9670"� 415 N 61h Street, Bldg 8. Shelton,WA 9858 Fax: (360)427-7787
j\ MASON COUNTY , :Ail
n r 1 COMMUNITY SERVICES
'\ j Building,Planning.Environmental Health,Community Health
APPLICATION FOR WELL SITE INSPECTION
Permit Number Payment Information Instructions
^
WEL Receipt Number 1 -C l�`Ut 1. Complete Part 1. Incomplete applications will be rejected
cylV .).3 ' ❑ Cash 2. Attach a detailed plot plan
❑ Check 3. Clearly stake out or flag the well site
4. Submit application and appropriate fee to Mason County
Q ChoU Date of Payment- L 1 - 4-y Public Health. Refer to Mason County Environmental Health
fee schedule for cost.
PART 1: Applicant/Parcel Identification
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Water System Name vcGl/�OY{'�fffi t CLL k2tJZ s List.,r� ��
Site Address i0 C5L �B�/u'qqn f1P PE(�S-Ae 24,n ikA C1) /
Applicant bXYL74/ 1-J-tL _ Phone ( t4
Mailing Address ?.v. 3C7— 337 --
City 1„0/7jun State 1A)A, Zipygyz
Parcel Number / - `-9aeto4_
Directions to Site 0 R
a milt .1
Water Source is: New ❑ Existing System Type: Nell ❑ Spring No.of Proposed ConnectionsS
L ,-
PART 2: Health Department Review(Staff Use Only) 71 yrj510u�'- Cute ❑E-
VES NO NA gCnil" is a4a-c!
Evidence of existing sources of contamination within 100 foot radius of water source? Ant
El *d ❑ (drainfields, tanks, buildings; indicate distance on plot plan) C„3jp0-190- \
Are there roads within the 100 foot radius of the water source? If so, is roadrS•unty or State.liyi-J
❑ ❑ What is distance to ROW? SS•
❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
❑ ❑ Is the well cap satisfactory?
❑ 0 Screened and vented? 2 t t
❑ The well casing extends Z above level ground/concrete slab?l � (circle one)
❑ ❑ Is there evidence of a surface seal? i[p Butt 6 /,3-1
.❑ ❑ Does the seal appear adequate? (qJ5 : (,�� IZ2�2j1
❑ Ly ❑ Is a variance necessary for well site approval? �� _ l� 67 231
Comments �/!�kU- 57/lehspeckal_ani -
Pass Fail Inspector_, Date to II0120 Z3
This form may be scanned and available for public view on the Mason County Web site.
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