HomeMy WebLinkAboutWEC2010-00107 - WEC Application - 10/22/2010 MASON COUNTY v
PUBLIC HEALTH OCT 2 .1 261111
"Always Working For a Safer, Healthier Mason County
426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584
SHELTON (360) 427-9670 ELMA (360)482-5269 BELFAIR (360)275-4467
WEB http //www.co.mason.wa.us FAX (360)427-8442
NOTICE OF INTENT TO CONSTRUCT A WELL f f WEC:
Receipt Number:
�C�O 1 V Q-U
ACT Q 2 2( t� 1. Complete Part 1, Fee $77.00 incomplete applications will be rejected
2. Attach a plot plan and vicinity map
e, 3. Submit this completed application with appropriate fee(s) $75.00 a minimum of 24
Recgive(
r%L hours in advance of initiating well construction.
4. The Mason County Health Dept. must receive notification at least 24 hours prior to
the drilling of the well
PART 1: Applicant 1 Parcel Identification
Site Address (_10 ( ) C 1(A roc -r a Start Card # 2, D( )
Drilling Firm Phone U,QC_�33glF _
Applicant Phone goAC2
Mailing Address aSQjo
City SkP I-kf 3s� State Zip CiRSeq
Parcel Number r')al D Sk 0nO I U
Directions to Site
Is the well site within 100 feet of salt/seawater? ❑Yes ❑No
If yes, a variance from DOE is required. Have you applied / received (circle one)a variance? ❑Yes ❑No
� j rir...n - A In r4�a
Appli ant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG # Called In
❑ ❑ Driller on Site?
❑ ❑ Is the well capped and Vented?
❑ ❑ Is there evidence of a surface seal?
❑ ❑ Is there a 2"annular space on all sides of the casing?
❑ ❑ Has the seal Slumped?
❑ ❑ Is the well flowing or is there evidence of other leakage?
❑ ❑ Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long?
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments
Pass Fail Inspector Date