HomeMy WebLinkAboutWEL2002-00026 - WEL Application - 6/5/2002 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
D PO BOX 1666 SHE-TON,WA 98584
SHE-TON (360)427A670
JUN 0 5 2002 FAX (360)427-7798
ELMA (360)482-5269
HEAL}�p� BELFAIR (360)275-4467
SERVICES SEATTLE (206)464-6968
APPLICATION FOR WELL SITE INSPECTION
Receipt#�q`'2s Date `J D-I Received By�IN /1 Tidemark#WEI%-- ��yy--����
INSTRUCTIONS coca- -"` ('0
1. Provide a location sketch and a detailed plot plan. The location sketch should be detailed sufficiently so that a field inspector can
easily find the site. The detailed plot plan shall show the precise location of the well,dimensions of the property,the location of
all existing septic systems within 100 ft of the well,and the location of any structures on the property.
2. Clearly stake out or flag the well site.
3. Submit the completed application and fee to the Health Department,PO Box 1666 Shelton,WA 98584
APPLICANT/PARCEL IDENTIFICATION
WATER SYSTEM NAME b/,' T L E z- / tiV/1 T 64 SYSTEM
WNERNAME 64AT Z- F 7-7 / &AcN A T7 ihl TELEPHONE 960 27 S--Z /Y�Kf
PPLICANTNAME TASonT L. Qc"RTf/lQ Grr+F TELEPHONE.Z66 5.S% -SS'�9 c4LL
SITEWATER SYSTEM ADDRESS AIF 6 £ £7/n( �6 '-Il 17Wi}T TO GBLigle WA QyS2r
]LING ADDRESSZIP q SI00 MlLP J/ rGL /J R �RT- GRLHAR/) wR
CITY STATE
ASSESSOR'S
GG L 3— L-3 Q o ASOR'S PARCEL NUMBER J. 3 G / 7 3
SUBDIVISION OFAPPUCABLE) 1 Q-2 S PZt' .Z N- 6 r DIV BLK LOT
DIRECTIONS FOR LOCATING SITE: (L n IGFLFA X' 11 " TO LZAP 61 -121- aTTo 70
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WATER SOURCE IS:_NEW5-R IXISTING;_WEl10R _SPRING _NUMBER OF PROPOSED CONNECTIONS