HomeMy WebLinkAboutWEC2011-00006 - WEC Application - 2/25/2011 MASON COUNTY
PUBLIC HEALTH
"Always Working For a Safer, Healthier Mason County"
415 North 6" ST. PO BOX 1666, SHELTON WA 98584
SHELTON (360)427-9670 ELMA (360)482-5269 BELFAIR (360) 275-4467
WEB htto://www.co.mason.wa.us FAX (360)427-8442
NOTICE OF INTENT TO CONSTRUCT A WELL
Receipt Number: ( WEC:
1. Complete Part 1, Fee$.77.00 incomplete applications will be rej cted
2. Attach a plot plan and vicinity map
3. Submit this completed application with appropriate fee(s) $77.00 a minimum of 24
Date Received 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 I Parcel Identification �n
Site Address F ;�T �� Rem G,/�� � Start Card#
Drilling Firm Jl�2 _I)oIu,IluL d Phone
Applicant /1�0�f},;�� P-1 bL F - ad I rw�� Phone
Mailing Address P 0 r fC / /
City R I4 State t/ zip �7 Z
Parcel Number e7 � D D 2 2-i 7Z�,
Directions to Site /Jim 9� ,n Ltd }
Is the well site within 100 feet of salt/seawater? ❑Yes �No _ O
yes, from E is required. Have you applied/received (circle one) a variance? ❑Yes ❑No
,If yes, n
AppFcant/Agent Signature
PART 2: Health Department Review(Staff Use Only) sdzr�
Y NO TAG# Called I
Y9 ❑ 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 a set-backs appear to be appropriate?
Comments Q �S 1 l� S
as Fail Inspector Date 3ZI6111