HomeMy WebLinkAboutWEL2018-00030 - WEL Application, Design, Letter - 7/12/2018 (2) JUL, 1 2 2018
MASON COUNTY
COMMUNITY SERVICES BY:------------
awuyra,.wyr-w.wwwmv..w.a.sS
415 N 6r'Street,Bldg 8,Sharon WA 98584
Shelton:(360)427-9670 ext 400 •r Belfair..(360)275-4467 etd 400 < Elma:(3W)482-5259 etd 400
FAX(360)427-7787
APPLICATION FOR WELL SITE INSPECTION
Permithlumber Payment information . Instructions
WEL�In Receipt Number 1. Complete Part 1. Incomplete applications will be rejected.
O ❑ Cash 2. Arch a detailed plot plan
❑ Check 3. Clearly slake out flag the well she
4. Submit application
and appropriate tee(Mason County
KJ Date of Payment Environmental Heath Fee Schedule)to Mason County
Public Health.
PART 1:Applicant/Parce!Adentification
Water System Name /C 0 d 1 n50-r'r (ye(y. Oe a
She Address 55 E
Applicant 213 n tei Phone -[,,o- 62t) -43So
Mailing Address 1
City t.r.J Zip S'g Sa It
Parcel Number O O O
Directions to Site ( o f d O
I-I h 4
Water Source is:❑ New ❑ Existing Sy ter pre: ❑Well ❑ ing No.of Proposed Connections_
PART 2:Heath Depa Revie St Us nly)
YES NtqO NA
[IYV ❑ Evide of existin s s of contaminatio thin 100 t radius of water source?
(dminfi ds,tanks, ings; indicate dista on plot p n)
❑ ❑ Are there oads wi in the 100 foot radi of the water urce?If so, is mad private, County or te.
What is dis ROW?
❑ ❑ Does the ground slope away from a water source ?(show slope on pi plan)
J4 ❑ ❑ Is the well cap satisfactory?
❑ ❑ Screened and vented? ,> I I
❑ The well casing extends ) L show:Is nd/concrete slab?(circle one)
ja ❑ ❑ Is there evidence of a surface seal?
�d ❑ ❑ Does the seal appear adequate?
❑ W ❑ Is a variance necessary for well she approval?
Comments
❑ Pass ❑ Fail Inspector Date
fi wigs In this raAm reflect observed con hors as they exated on ills clay of the saa irapal5w,No claim g mada erq+mss W implied of be future
siw,,aworfailure a Ml system_WellSfle passage does not mrctihile water system approval Water System approvaris a two pan pmoess.
1)Passage of be well site.2)Approval Mthe water system design.Orce the well sfle 1s passed be water System design may be surmised for review
This form may be scanned and available for public view on the Mason County Web site.