HomeMy WebLinkAboutWEC2020-00151 - WEC Application - 8/31/2020 w
�'� p ��k 415 N 6TH STREET, SHELTON,WA 98584
MASON COUNTY SHELTON: 360-427-9670, EXT.400
=ter` ''F COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
ELMA: 360-482-5269, EXT. 400
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`dv Building,Planning,Environmental Health,Community Health FAX: 360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
q 1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number • 3131 2. Attach a plot plan and vicinity map.
c3a2.—C_)' 0 Cash 3. Submit this completed application with appropriate fee a minimum
0 Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
GC 161 Date of Payment�d31faC) 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 420 SE Legacy Lane Start Card# WE40636
Drilling Firm Advanced Drilling Phone 360 273-7735
Applicant Frank Near Phone 206 819-3522
Mailing Address 220 E Misty Acres Lane
City Shelton State WA Zip 98584
Parcel Number 31 91 1-33-50020
Directions to Site 101 S to SE Old Olympic Hwy. to Bloomfield rd. Turn onto Dahman Rd. Follow "Near
Property" signs 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
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 sage restricti s and additional fees ay apply to all new wells drille after January 19`h,2018 per ESSB 6091.
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Appl ant/Ag t Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# ►VZ I33 Called In -gy`a (ak , zl- ZQ `2 1
❑ L`- Driller on Site? 1
LI ❑ 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?
❑ ,0----- Has the seal slumped? * s3 l ci44 ,
❑ ,I Is the well flowing or is there evidence of other leakage?
❑ Er Is there evidence of cascading water? (�
❑ ❑ Is there evidence that the seal is at least 18 feet long? tip�'C c6Q' sC��
❑ Do the well site set-backs appear to be appropriate?
Comments ra> sr Devrsl-re Ate v`— - tr_,6,.43—i-e -e-t v
❑:Pass ❑ Fail Inspector /Ic /t{&1LDate il \ 12
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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