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HomeMy WebLinkAboutWEL2024-00044 - WEL Application - 10/16/2024 MASON COUNTY �2 C E W 9 COMMUNITY SERVICES uu OCT 16 2024 au ry4 rr.nro.FM,mmmld N W IR Cemn,n�Yr1uI,M1 415 N 6e Street,Bldg 8, By Shaken WA 98584 Shelton: (360)427-9670 ext 400 4 Beffelr(360)2754467 ext 400 4 Elma:(360)4825269 ext 400 FAX:(360)427-7787 APPLICATION FOR WELL SITE INSPECTION Permit Number Payment Information Receipt Number 22 1. Complete Pa'/ Instructions WEL n 1, Incomplete applications will be rejected. 2. Attach a detailed plot plan. '1-oc—Do ❑ Cash 3. Clearly stake out or Flag the well site. W, Check I/ 4. Submit application and appropriate fee to Mason County Date of Payment �'� '27 Public Health, Refer to Mason county Environmental Health Fee schedule for cost. PART I. Applicant I Parcel Identification Water system Name Rolling Acres Site Address 1100 E Johns Prairie Rd Shelton WA 98594 Applicant Thomas Wolter Phone (206) 200-3325 Mailing Address PO Box 76,Allyn, WA 98524 City Shelton State WA zip 98684 Parcel Number 320082100000 Directions to Site From Northcliff Rd turn right onto E Johns Praire Rd then turn right at 1100 E Johns Prairie Rd.Follow Th.dirt road,go straight at the first Intersection then turn leg at the first and second forks In the road. Water Source is: ®New ❑ Existing System Type: IN Well ❑Spring No.of Proposed Connections 14 PART 2: Health Department Review(Staff Use Only) YES Ng NA ❑ ❑ Evidence of existing sources of contamination within 100 fool radius of water source? (drainfields,tanks,buildings:indicate distance on plot plan) ❑ �, ❑ Are there roads within the 100 fool 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) ❑ ❑ 1j� Is the well cap satisfactory? ❑ ❑ )!q Screened and vented? The well casing extends above level ground/concrete slab?(circle one) ❑ ❑ Is there evidence of a surface seal? ❑ ❑ Does the seal appear adequate? ❑ % ❑ Is a variance necessary for well site approval? �7, �3 7 Cornr ants Pass ❑ Fail Inspector I1� Date This form ma be s nd avallab a for ublic view on the Mason I 1 r q - 41I ails le ass he Co Web st .e f VK2,11lBa .Q llpm b9 s Pu ferrevMw JAEH FormstDRINKING WATER FORMSIDrinking Water Well Site Inspection App.docx Rmscd: 3/20/2017