HomeMy WebLinkAboutWEL2025-00037 - WEL Application, Design, Letter - 7/7/2025 ANNINIIIIIIIIMIIIIIIINIIIIIIIIIIii
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': MASON COUNTY
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x COMMUNITY SERVICES
'q..,, Building,Planning,Environmental Health,Community Health
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415 N 6t1 Street, Bldg 8,
Shelton WA 98584
Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 •:• Elma:(360)482-5269 ext 400
FAX: (360)427-7787
APPLICATION FOR WELL SITE INSPECTION
Permit Number Payment Information Instructions
. 3�� 1. Complete Part 1. Incomplete applications will be rejected.
WEL Receipt Number 2. Attach a detailed plot plan.
p�Qt �c ❑ Cash 3. Clearly stake out or flag the well site.
C�O0 3` 1 0 Check 4. Submit application and appropriate fee to Mason County
Date of Payment ����J Public Health. Refer to Mason county Environmental Health
Fee schedule for cost.
PART 1: Applicant I Parcel Identification
Water System Name Hoodsport Heights
Site Address XX N Hoodsport Heights Drive (currently unaddressed)
Applicant Dahl Properties, LLC Phone 360-740-0345
Mailing Address 261 N Hamilton RD
City Chehalis State WA Zip 98532
Parcel Number 422104450050
Directions to Site From US 101 N, turn left onto WA-119 N/N Lake Cushman Rd; turn right onto
N Hoodsport Heights Dr(1.6 miles from US 101)
Water Source is: ® New ❑ Existing System Type: ® Well ❑ Spring No. of Proposed Connections 6
PART 2: Health Department Review(Staff Use Only)
YES NO NA
❑ , ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
A El ❑ Are there roads within the 100 foot radius of the water source? If so, is road r'rivat:, County or State.
What is distance to ROW? /77
El ❑ Does the ground slope away from the water source site? (show slope on plot plan)
El ❑ Is the well cap satisfactory?
❑ ❑ X Screened and vented?
XThe well casing extends above level ground /concrete slab? (circle one)
El El /`'" Is there evidence of a surface seal?❑ ID Does the seal appear adequate? utt-1 u( F '09 if
❑ , ❑ Is a variance necessary for well site approval? — l Z 3. 16$(esg
Comments I, ,,fit 51k p(e fr Cf`C� ,
PI Pass ❑ Fail Inspector Date 7( 15/ N
This form may be scanned nd available for public view on the Mason County Web site.
,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
=ss or failure of this system.Well Site passage does not constitute water system approval.Water system approval is a two part process.
- -- ..proval of the water system design.Once the well site is passed the water system design may be submitted for review
J:\EH Forms\DR1NKING WATER FORMS\Drinking Water Well Site Inspection App.docx Revised: 1/20/2017
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Mason County
rrol7 ',MASON COUNTY Mason County - Public Health
COMMUNITY SERVICES
415 N. 6th St.
_ Building 8
Shelton, WA 98584
360-427-9670 ext 400
www.masoncountywa.gov
WEL2025-00037 WELL SITE INSPECTION
PROJECT DESCRIPTION: ISSUED: 07/15/2025
SITE ADDRESS: UNKNOWN MASON COUNTY
EXPIRES: 01/03/2026
PARCEL: 422104450050
APPLICANT: DAHL PROPERTIES LLC OWNER: DAHL PROPERTIES LLC
261 HAMILTON RD N 261 HAMILTON RD N
CHEHALIS, WA 98532 CHEHALIS, WA 98532
1.360.740.0345
FEES: Paid Due
Well Site Inspection $255.00 $0.00
Totals : $255.00 $0.00
REQUIRED INSPECTIONS
Well Site Inspection
CONDITIONS
* NOTICE: All proposed connections to new wells are subject to water adequacy requirements at time of building permit per
Mason County Title 6.68 Water usage restrictions and additional fees may apply to new connections and/or wells drilled after
January 19th, 2018 per ESSB 6091.
* No claim is made, express or implied of the future success or failure of this system. Well Site passage does not constitute
water system approval. Water system approval is a two part process. 1) Passage of the well site. 2)Approval of the water
system design. Once the well site is passed the water system design may be submitted for review.
* Well Site must be clearly staked and/or flagged prior to inspection.
Printed by:Jeff Wilmoth on:07/15/2025 02:25 PM
Page 1 of 2
Mason County
VHF MASON COUNTY Mason County - Public Health
COMMUNITY SERVICES
415 N. 6th St.
Building 8
Shelton, WA 98584
360-427-9670 ext 400
www.masoncountywa.gov
WELL SITE INSPECTION WEL2025-00037
I hereby certify that I have read and examined this application and know the same to be true and correct.
All provisions of Laws and Ordinances governing this type of work will be complied with whether
specified herein or not. The granting of a permit does not presume to give authority to violate or cancel
the provisions of any other state/local law regulating construction or the performance of construction.
Issued By:
Contractor or Authorized Agent: Date:
Printed by:Jeff Wilmoth on:07/15/2025 02:25 PM
Page 2 of 2