HomeMy WebLinkAboutWEL2024-00044 - WEL Application, Design, Letter - 10/16/2024 (2) MASON COUNTY Im
COMERVICES e,s4� � rrw415N e Street,Bldg 8,
Shelton WA 98584
Shelton: (360)427-9670 ext 400 4 Bega r�(3()24 4 48 Bext 400 4 Elma:(360)482-5269 eM 400
APPLICATION FOR WELL SITE INSPECTION
permN Numhar Payment Information Inetructlonp
1. Complete Part 1. Incomplete applications will be re)ecled.
WEL y Receipt Number 2�/-df�.1G5 2, Attach a detailed plot plan.
❑ Cash 1 Clearly stake out or flag the well site.
Check 4, Submit application and appropriate fee to Mason County
r/ Public Health. Refer to Mason county Environmental Health
Date of Payment /�'� 'Z/ Fee schedule for cost.
PART 1:Applicant I parcel Identification
Water System Name Rolling Acres
Site Address 1100 E Johns Prairie Rd. Shelton WA 98584 Phone (206)20_ 03325
Applicant Thomas Wolter
Mailing Address PO Box 76, Allyn, WA 98524
City Shelton
State WA Zip 98584
Parcel Number 320082100000
Directions to Site From Northcliff Rd hum fight onto E Johns Prairie Rd, then turn d Mal 1100 E Johns Prairie Rd. Fellow
the dirt road, go straight at the first intereec0on then.um lei.at the first and second forks in the road.
Water Source is: ®New ❑Existing System Type: ®Well ❑Spring No.of Proposed Connections 14
PART 2: Health Department Review(Staff Use Only)
YES NQ NA
[IS
'I�"Q' ❑ Evidence of existing sources of contamination within 100 fool radius of water source?
(drainfrelds, tanks,buildings; indicate distance on plot plan)
❑ ❑ Are there roads within the 1 oo foot radius of the water source? If so, Is road private.County or State.
What is distance to ROW?
❑ Does the ground slope away from the water source site?(show slope on plot plan)
❑ ❑ �. Is the well cap satisfactory?
❑ ❑ AScreened and vented?
The well casing extends above level ground I concrete slab?(circle one)
❑ ❑ Is there evidence of a surface seal?
❑ ❑ Does the seal appear adequate?
- ❑ ❑ is a variance necessary for well site approval? Yh 7 V 3 —7 7 G
Comrdents YL-13, -7 I-0
Date ld,_ 21V
Pass ❑ Fail Inspector G
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3.�HF1 Forms\DRINKING WATER FORMS\Drinking Water Well Site Inspection App.docx Revised: 1/20/2017