HomeMy WebLinkAboutNO PERMIT OPENED NO FEES PAID - WEL Application V`ilreirr MASON COUNTY ' Date Received:
r `s COMMUNITY SERVICES Amount Received: I Received By:
Building,Planning,Ern'vonmental Health,Community Health
•Hi-res‘'
415 N.6`"Street,(Bldg 8)—Shelton,WA 98584 1 W E L
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 i
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PHONE
Dustin Theoharis 253-335-1283
MAILING ADDRESS—STREET,CITY,STATE,ZIP
2073 East Scorpio Place Chnadler, AZ 85249
SITE ADDRESS—STREET,CITY,STATE,ZIP
17131 NE North Shore Rd
PRIMARY PARCEL NUMBER(WELL SITE) 322205003050
SECONDARY PARCEL NUMBER(IF APPLICABLE3222O50030't9
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
0 New 0 Existing 0 Well 0 Spring .60 .13
PROPOSED WATER SYSTEM NAME(REQUIRED)
PROJECT DESCRIPTION SFR on parcel 322205003050. The well has been used for both parcels since the well was
dug in the 70's.
DIRECTIONS TO SITE/CONDITIONS
WA-300 W continue onto NE North Shore Rd.
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines, easements,etc...)
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Submittals Checklist: (these additional items will bE
r d
Satisfactory Bacteriological sample (this may bE �l
Ll� Sat ry 9 is not yet drilled)
,Well Log with pump test or 4-hour capacity test Is ed no document)
CL otice to Future Property Owners recording (re ) file)
eptic Records (additional locating requiremen
used: 10/13/2021
This form may be scanned and available for public view o.._._ -
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Staff Use Only
Review Step 1: Well Site Inspection:
YES NO NA
❑ ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
❑ ❑ ❑ Are there roads within the 100 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?
❑ ❑ ❑ 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?
Comments
El Pass ❑ Fail Inspector Date
MINIMUMS
Review Step 2: Two-Party Review:
YES NO NA
❑ ❑ ❑ Water Well Report with adequate pump test on file?
If NO, date of Capacity Test Driller GPM
❑ ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test
❑ ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN
❑ ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
❑ Approved ❑ Denied Reviewer Date
Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claim is made, express
or implied of the future success or failure of this system. Well site approval does not constitute water system approval. Water
System approval is a two-part process.
All proposed connections to new wells are subject to water adequacy requirements at time of building permit per MCC 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled after January 10, 2018 per ESSB 6091.
Revised: 10/13/2021
This form may be scanned and available for public view on the Mason County Web site.
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