HomeMy WebLinkAboutWEL2007-00049 - WEL Application - 4/20/2007 Mason Land Records Imaging
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MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
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426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584
SHELTON (360)427-9670 ELMA (360)482-5269 BELFAIR (360)275-4467
WEB http:/lwww.00.mason.wa.us FAX (360)427-7798
APPLICATION FOR WELL SITE INSPECTION
ECEIVE Receipt Number: 651op7- 531 WEL: d 7-- y9
APR 2 0 2007 1. Complete Part 1.Incomplete applications will not be accepted
,t 2. Attach a detailed plot plan and vicinity map
ENVIRONMENTAL 3. Clearly stakeout or flag the well site
Ived 4. Submit application and appropriate feels)to the Mason County Health Dept,
PART 1: Applicant/ Parcel IderdRlcatlon
Water System Name �n
She Address '4W N
Applicant Phone
Mailing Address G�- ' T l4JA /YiL �NF�
city k&M u i5e, state WT zip 961 y3— 9?;72z
Parcel Number L;22.?s� �.. /y — LIA0/ C)
Directions to Site iAll, AtLyly' LY ek�
Water Source is New [I Existing Re -Number of
System Type: 14 Well ❑ Spring Proposed Connections
PART 2: Health Department Review(Staff Use Only)
YES NO , NA
`❑ JW ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainflelds,tanks,buildings;indicate distance on plot plan)
❑ ❑ Are there roads within the 1001 radiu f the star#� ?If so,is road private] County or Stat
What is distance to ROW 7 .I w W AD � e'r' -'p,I!e �eCa9'sy , prC �to
❑ EL ❑ Does the ground slope away from the water source site?(show slope on plot plan) a;-�i ' t 4�
❑ ❑ tg. Is the well cap satisfactory? S r 1
❑ ❑ Screened and vented7 ` `a K$ brµSN
The vreli casing extends above level ground I concrete stab?(circle one)
❑ ❑ Is there evidence of a surface seal? -1i ti/,x ryy ,69Aj +'-
❑ ❑ Does the seal appear adequate?
❑ ❑ Is a vanance necessary for well site approval? Gam/ �av ✓a 51aLc�-r '
Comments 1d/la2rf -'D LP ?i)r ..'i 75 ,1 9 3 h10 . S�.' 0!f &rS Ab
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Pass Fail � Impostor Date
Findivg and dxmmivlioos ofWie mviewrelket obwvd 000GaooeutbcY exiard rpe 4sY oflhe fire mrPemiw No ceim is made,e@rcaamimpliM of l6e
(more auettss or ftilurt of au ayvtem.
Well gib Pumge dov not emoimm wcmrysbm a,novii,Wmm ryna eppmvd is a rxroputprorm.1)Putage ofee wdl ule.2)Altpovd ofthe ware 9Y91m1
.O�thewell vm ie the water teemdeei me be nibmivM farmview
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