HomeMy WebLinkAboutWEC2021-00095 - WEC Application - 4/22/2021 "` r`�^�z,. 415 N 6TH STREET,SHELTON,WA 98584
/0 , MASON COUNTY SHELTON: 360-427-9670, EXT.400
'��' i COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
:—_ ELMA:360 482-5269, EXT.400
1,,, ,7 Building,Planning,Environmental Health,Community Health
a FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number 21-„, 3qlf 2. Attach a plot plan and vicinity map.
a 1. - ❑ Cash 3. Submit this completed application with appropriate fee a minimum
0 Check of 24 hours in advance of initiating well construction. Refer to
5 Mason County Environmental Health fee schedule for cost.
��� Date of Payment 'l/ 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/Parcel Identification
Site Address 2g-d/ ,�� /T h !�Cle. P le/Z. y.,�
(� :' Start Card# le/Z.
/
Drilling Firm C' e,4, 71-ei—, 0,- ,')1 �'—M. Phone ?A ,?0- Sex J'
Applicant 4 v/ A 01-i.�c`'J1-,0 �-,c Phone .{.Q-* 7 2?' ne-
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Mailing Address � 7y�//67 J�`l S 7 J- .�L✓
e city / , , -,t/ re er, State 4-"IA Zip 9 3 7-1---
Parcel Number 22 3.3CV1-7(0n33(,
Directions to Site
• Is the well site within 100 feet of salt/seawater? ❑YesNo
If yes, a variance from DOE is required. Have you applied/received (circle one)a variance? DYes` tdo
NOTICE All proposed connec• s to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
Water usage restricts dition ees may apply to all new wells drilled after January 19e,2018 per ESSB 6091.
Applicant I Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In ,v(1'1 (2( Fc z t<-l 1`t(z 1
❑ ❑ Driller on Site? cs,._1 „,.- c,( (s>
❑ ❑ Is the well capped and Vented?
El ❑ Is there evidence of a surface seal?
El ❑ Is there a 2"annular space on all sides of the casing?
El ❑ Has the seal slumped?
❑ ❑ Is the well flowing or is there evidence of other leakage?
❑ El Is there evidence of cascading water?
El ❑ Is there evidence that the seal is at least 18 feet long?
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments /` 0-1 (6-(Sr6G -8 L - 0-4A.C, l
❑ Pass ❑ Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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PPROVED
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MASON COUNTY ENVIRONMENTAL HEALTH 1?AULA JOY JOHNSON'.:4qh.t
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