Fillable Lewis County Public Health & Social Services Environmental (Lewis County)

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Lewis County Public Health & Social Services Environmental (Lewis County)

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The Lewis County Public Health & Social Services Environmental (Lewis County) form is 1 page long and contains:

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  • 10 check-boxes
  • 20 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Lewis County

BROWSE LEWIS COUNTY (WA) FORMS

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Well Site Inspection Form
This section to be completed by applicant:
Water system/Applicant:__________________________
Location/Site Address:____________________________________________________________________
Short Plat/Long Plat #:_________________________
Tax Parcel #:__________________ ¼ ¼ Sec. Twnshp
Range E/W
Representative:
Owner Name:___________________________
Address: _________________________________
Phone: ___________________________________
Email: ___________________________________
Owner
Authorized Agent
Signature: __________________________________
Date: ______________
Check One:
This section will be completed by Lewis County Environmental Health Staff
WS#:_______________________ Planning Review #:_____________________________
Date Inspected:____________________ Expiration Date:___________________
Permit Number: _____________
Master Site review:___________
Date Received: ______________
Permit Tech: ________________
A well site approval is effective for 2 years
Land use adjacent to the well site: ______________________________________________________________________
Acknowledgment and Permission to Enter
I understand that any permits issued by Lewis County, consistent with the attached site plan, are valid ONLY if construction is in according
to this plan and all other conditions of the permit are followed.
Further I understand that County regulations require permission to County personnel to enter private property to conduct inspections.
By my signature below, permission is granted for representatives of Environmental Services to enter and remain on and about the
property for the sole purposed of performing required inspections relating to this permit.
By my signature below, I certify that I am either the current legal owner of this property or their authorized representative. With this
document, I take full responsibility for the lawful actions that this document allows.
Prior notification of the date of inspections will take place is:
Not required
Required
(________) ___________________ (Must provide phone number where applicant/representative can be reached)
Address: _________________________________
Phone: ___________________________________
Email: ___________________________________
Lewis County Public Health & Social Services
Environmental Services Division
2025 NE Kresky Ave, Chehalis, WA 98532 ● Phone: (360) 740-1146 ● Fax: (360) 740-1245
Inspection Findings
1. Map provided was accurate, based on your observations at the well site.
Yes No N/A
___________________________________________________________________________________________
___________________________________________________________________________________________
Group A Group B Commercial Shared Two ConnectionTwo Party
S:\COMMUNITY DEVELOPMENT\Applications & Forms\Currently on Website
Updated January 2021
*See definitions on the last page of this application.
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2. Slope of ground within the well site is such that potential contamination Yes No N/A
due to runoff and flooding is at a minimum.
___________________________________________________________________________________________
___________________________________________________________________________________________
3. Site is safe from manmade and natural disasters. Yes No N/A
______________________________________________________________________
______________________________________________________________________
4. Public or private roads are placed as far as possible from well site. Yes No N/A
a. If roads are present in the well site are they paved and properly ditched Yes No N/A
or drained to exclude surface runoff from the well?
___________________________________________________________________________________________
___________________________________________________________________________________________
5. Contamination sources such as septic tanks/drain fields, chemicals, underground storage tanks, surface
water, and dry wells are absent from the well site.
Yes No N/A
______________________________________________________________________
______________________________________________________________________
Proposed well location inspected, well has not been drilled Yes No
S:\COMMUNITY DEVELOPMENT\Applications & Forms\Currently on Website
Updated January 2021
Existing Wells:
Well log: ___Yes _____No Start Card #: Unique Well ID:____________________
6. The surface seal is present and satisfactory. Yes No N/A
_____________________________________________________________________________________
_____________________________________________________________________________________
7. The sanitary seal is satisfactory and properly sealed Yes No N/A
8.
There is a satisfactory concrete slab around the casing. Yes No N/A
9.
The casing terminates at 6 to 12 inches above the floor. Yes No N/A
(if in flood plain must be above flood level)
10. Has a proper air vent and the vent is screened. Yes No N/A
11. Conduits and junction boxes are sealed Yes No N/A
12. If the well is in a pit, it’s adequately constructed to prevent flooding. Yes No N/A
__________________________________________________________________________________
13. General housekeeping is satisfactory.
Yes No N/A
_________________________________________________________________________________
14. The wellhead is accessible for maintenance. Yes No N/A
Well constructed with an
Well constructed with a well seal
overlapping well cap and pitless adapter.
containing a compressible rubber gasket.
Diagrams obtained from the University of Missouri Extension web site 4/17/08.
General:
Diagrams obtained from the University of Missouri Extension web site 4/17/08.
General:
S:\COMMUNITY DEVELOPMENT\Applications & Forms\Currently on Website
Updated January 2021
15. Well site is legally protected against contamination by covenants. Yes No N/A
16. A source meter is installed. Yes No N/A
In your opinion, overall, is the well and/or well site:
_______Satisfactory
_______Satisfactory, with correctable deficiencies (see comments)
_______Not satisfactory
Sanitarian:_________________________________
Date:_________________
Comments:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Group A Well: Serves a Group A Water System under the jurisdiction of the
Washington State
Department of Health.
Group B Well: Serves a system with three or more connections but less than 15 and populations of
less than 25 people per day or one or more connections that serve a usage identified in LCC8.55.020
or LCC8.55.040((81). See LCC8.55 for further requirements.
Commercial: A facility with two or less connections and less than 25 people per day. Most small
businesses.
Two Party Well: Serves two dwelling units on separate properties. See LCC8.55.020 Table 1
Shared Well: Serves two dwelling units on the same property. See LCC8.55.020 Table 1
Two Connection: Serves two dwelling units one of which is an ADU or temporary ADU not
incorporated into the main structure of the primary residence.
Approval of a well site or preliminary plat does not constitute or imply approval of the proposed
water system. Approval of the water system is contingent upon the water system construction and
management plan meeting rules and regulations of LCC 8.55 and the State of Washington.
S:\COMMUNITY DEVELOPMENT\Applications & Forms\Currently on Website
Updated January 2021
Definitions:
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Lewis County Public Health & Social Services Environmental (Lewis County)

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Completed 21 January 2021

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