HomeMy WebLinkAboutWEL2025-00091 - WEL Application - 7/18/2025 MASON COUNTY
•'lb Wi COMMUNITY SERVICES ! � �
�.. J Bu,din .Planning.enm,onmental Hwmm, mm Gurvn health
415 N 6'"Street, Bldg 8, FCFi`Fp 101f
Shelton WA 98584
Shelton'. (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 C Elma:(360)482-5269 ext 400
FAX (360)427-7787
APPLICATION FOR WELL SITE INSPECTION
Permit Number Payment Information Instructions
Eh Receipt Number j � 1. Complete Part 1. Incomplete applications will be rejected.
rti. Yp , ❑ Cash 2. Attach a detailed plot plan.
`� Check 3. Clearly stake out or flag the well site.
4. Submit application and appropriate fee to Mason County
Date of Payment I I Public Health. Refer to Mason county Envirunmen+al Health
Fee schedule for cost.
PART 1: Applicant/Parcel Identification I,, _ - --
WaterSystemName SOk(A. NAY S .s cy
Site Address ?5O t? j`—I- LIN
G
Applicantr_Sf)h , J Irgk Phone Off) — y37,5
Mailing Address (12 1 a VCIrij Cl
City C 'y�S \�r'\ State W I
pc Zip
Parcel Number _ 1 2_1 2-21 0 DD (QZ
Directions to Site y, , 11 W-4 3 — 123. (']71ey1 OC(o55 01. -17Jn.- 0ld (NQl
torLr-I- � r�n, f ) WPI) Sf}e_ Or?1
Water Source is: `A New E Existing System Type: �J Well ❑ Spring No. of Proposed Connections \ P
PART 2: Health Department Review (Staff Use Only)
YES ;ifrNO NA
❑ / ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
❑ X ❑ 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?
IV 0 E Does the ground slope away from the water source site?(show slope on plot plan)
❑ ❑ Is the well cap satisfactory?
❑ ❑ X Screened and vented? Ivo t,r/4/1l
❑ The well casing extends above level ground/concrete slab? (circle one)
❑ ❑ jg] Is there evidence of a surface seal? LG4a Hi-, 1 ?CI4S
❑ ❑ 1 Does the seal appear adequate? 1 Z; Li l I9
❑ j ❑ Is a variance necessary for well site approval? Lit -
Comments SI
�Q Pass 0 Fail Inspector Date 9/ZO
This form may be scann and available for public view on the Mason County Web site.
Flndaga IngdajAMVO mfleotcbpalyed conditions Whey existed on the day of the site inspection.No claim le made,express of Jobbed of the future
6aeaex or feWeieWthis syefeet.Well Site passage does riot constitute water system approval,Water system approval is alav prat process,
1).Freemsga afthe well site, APpmvei of the Water system design.Once the well site is passed the water systain design May be submerse NrfevfeW
.l llI FormsVDRINKING WATER FORMSV Drinking Water Well Site Inspection App.docx Revised: I/20/2017