HomeMy WebLinkAboutWEC2011-00021 - WEC Application - 4/18/2011 MASON COUNTY 11111
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 http/Mww.co.mason.wa.us FAX (360)427-8442
NOTICE OF INTENT
'�IITIO CONSTRUCT A WELL 2�
zcznvz "II Receipt Number: 517aoI I —�210 WEC �011— U� l
APR 1 8 2011 1. Complete Part 1, Fee$77.00 incomplete applications will be rejected
2. Attach a plot plan and vicinity map
BY _____ 3. Submit this completed application with appropriate fee(s) $77.00 a minimum of 24
to 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/Parcel Id'e/ntniication
Site Address ;9 t1 f U I{f t4o/Y f(�/� /T Start Card# G,! _
Drilling Firm ./ �r1 , Phone rA2
Applicant _� 'n/t �`/!/� �/� Phoneleo '37Z -,2"
Mailing Address Ltoc) _]'PO,d+-ftvlc c 4
City �'T �� State _ Zip : 5 ?`�]
Parcel Number --
"`
Directions to Site
Is the well site within 100 aft sr e9Wa r? []Yes o
If yes, a vana ce fro OE is required. Have you applie /received (circle one)a variance? ❑Yes [:]No
plicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
yES. NO TAG# Called In
❑ Driller on Site?
El El 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 2Sc /7
ass Fail Inspector Date 6�(