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HomeMy WebLinkAboutWEL2025-00101 - WEL Application - 8/27/2025 / � MASON COUNTY mt 71 9 COMMUNITY SERVIC O i AUG 2 7 2025 pa© 'Op � Building,Planning Environmental Health,Community Health 415 N 6th Street, Bldg 8, BY 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 I Instructions WEL Receipt Number a 5- la I 1. Complete Part 1. Incomplete applications will be rejected. c7CD 5- ❑ Cash 2. Attach a detailed plot plan. [ Check 3. Clearly stake out or flag the well site. CO 1 O I 4. Submit application and appropriate fee to Mason County J�^am` Public Health. Refer to Mason county Environmental Health Date of Payment 8/a' h 5 Fee schedule for cost. PART 1: Applicant/ Parcel Identification Water System Name We,l( i "Iti 1n d ht s V V c - SiteAddress XX F_ e-ii- j D (cL4dtecc IVe a �hp(Ich r-eAAApplicant f`LQ I/cV(S Phone Mailing Address 2 Lf(; N l/c.VtS ra) 24 City .V e I ft+ I I State WA Zip g,g rj 2g Parcel Number 2-7-2- 1 y— Z- ) 1 0 I O Directions to Site i ni I0 -ft E D,e t-`'3 P(I 1--e 61A *Q jcu'UJi St di, %b I t b\Ai d I---1- -Ill o kille I I I cc(--I'f nl. (S'-ee a-H-cc cll.,2 cf) il Water Source is: ( ] New ❑ Existing System Type: $ Well ❑ Spring No. of Proposed Connections 7 ,Acys PART 2: Health Department Review (Staff Use Only) YES X_, 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? 7f1., ❑ ❑ Screened and vented? I/ ❑ The well casing extends .)", above level ground / concrete slab? (circle one) ❑ ❑ Is there evidence of a surface seal? lit ❑ ❑ Does the seal appear adequate? t tic .21 ,/2/E, (4 7. k/d (pi / 1 ❑ Ey , ❑ Is a variance necessary for well site approval? Comments T y- 1 22-., 1 2_ V6 Pass ❑ Fail Inspector ' i`�h �rL Date i-� z This form scanned !".FI!ilable forpublic view on the Mason CountyWeb site. 5 T s o m may be a , indings in this review reflect observed conditions as t'-y existed on the day of the site inspection.No claim is made,express or implied of the future success or failure of this system.Wet 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 J:\EH Forms\DRINKING WATER FORMSIDrinking Water Well Site Inspection App.docx Revised: 1;20;2017 ...Itttttttttttt .... Mason County WA GIS Web Map . , ,, if .d. ......-. N. 1,4 . , ,„4, . ,„. _ ek 4.0 4,- r • 91111Itl0ihi>414,1 a,,,,,..., „, ir s. Y -., 4.11V . . , t� +d � • � a . iii\ak 4 i •• ' 4' lk,,,,leit. t. ar ,k ' _ v } '' 4.4111r4":" '' • f, it 1 T22N -R2W ills. - -- s t ' S • `�R 6 r. p a r, ! f ,.',ng t •9. Feet '� T>". x. ilk � - -- .'=til • 4„, 'a yr. , ', i' Sec Ion ) . . . - , • 6/3/2025, 3:10:36 PM1:3,061 (Aral 0 0.03 0.05 0.1 mi LJ County Boundary.? I + / r 'V l O l 0.04 0.08 0.16 km Z�ZI• No Filled 2. 4� O Tax Parcels (Zoom in to 1:30,000) Source:Esn,Maxar,Earthstar Geographics,and the GIS User Community O Sections 1-+ Townships Mason County WA GIS Web MapAppllcallon Mason County disdaims accuracy,reliability,or timeliness of website info,not liable for losses from reliance on it.https://www.masoncountywa.gov/disclaimer.php