HomeMy WebLinkAboutWEC2021-00018 - WEC Application - 1/26/2021 —' �n<y,t 415 N 6TH STREET,SHELTON,WA 98584
MASON COUNTY SHELTON:360-427-9670, EXT.400
'II' 1 COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
ELMA: 360-482-5269, EXT.400
yy Building,Planning,Envitonmental Health,Community Health FAX: 360-427-7787
�e
1' NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number I Payment Information Instructions
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number at)"�j�41 2. Attach a plot plan and vicinity map.
Cash 3. Submit this completed application with appropriate fee a minimum
T `ie Check of 24 hours in advance of initiating well construction. Refer to
ry _ Mason County Environmental Health fee schedule for cost.
O IS- Date of Payment 1IO�-�te...1 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant I Parcel Identification
Site Address Next to 20 E Northern Sky Drive Start Card# WE42362
Kn FfIc k R4 ? fl "1)R+LL t;S� Phone`36 -42-7-8444-'-� `2>S I'S"_'
Drilling Firm �PF�T�^9-
Applicant
Michael Eaton Phone 360-427-8174
Mailing Address 1522 Turner Ave
City
Shelton State WA Zip 98584
Parcel Number 42127-11-90020
Directions to Site North on Hwy 101, onto E Northern Sky Drive, on the left
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
NOTICE:All proposed connections to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
Water usage restrictions and addition fees may apply to all new wells drilled after January 19"', 2018 per ESSB 6091.
t,
App fG t/Agent ign ture
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
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018