HomeMy WebLinkAboutWEC2021-00158 - WEC Application - 8/27/2021 °J MASON COUNTY 415 N 6TH STREET, SHELTON,WA 98584
SHELTON:360-427-9670, EXT.400
'.11111119 r _ COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
2���~.�v�y Building,Planning,Environmental Health,Community Health ELMA:360-482-5269, EXT.400
.,,,,,t FAX: 360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number d,I-4W19 2. Attach a plot plan and vicinity map.
c Oc l , 0 Cash 3. Submit this completed application with appropriate fee a minimum
- Check of 24 hours in advance of initiating well construction. Refer to
C Mason County Environmental Health fee schedule for cost.
C.� 1,�7� Date of Payment 1a-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 `J lJ
Site Address LQ/2c- -"f *.,�7 c��®�'� (]I'= Start Card# 7 7��
Drilling Firm �GGG2CV/ct f•TP/ s Or-.`ti ,`� �i-7L . Phone
Applicant kg: 1. G`ipf.5TvL„) ,`Q L L C• Phone
Mailing Address 0•c2 . eel( J ���j
City ef'(f e' r`!€/ State �../A Zip 9(''
Parcel Number �_ ,.. Z.9 •._5 f eo-S^�
Directions to Site .tif S s-.-,_ Lc"-- ,
Is the well site within 100 feet of salt/seawater? EYes [1No
If yes, a variance from DOE is required. Have you applied/received (circle one) a variance? ❑Yes ENO--
NOTICE:All proposed connects to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
Water usage restrictions cla itiona s may apply to all new wells drilled after January 19th, 2018 per ESSB 6091.
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In 130124 � 43(3i, (2-I
L� ❑ Driller on Site?
❑ Is the well capped and Vented?
[^�/ El Is there evidence of a surface seal?
LK ❑ Is there a 2"annular space on all sides of the casing?
❑ Has the seal slumped?
CI p Is the well flowing or is there evidence of other leakage?
❑ Is there evidence of cascading water? ill .`(I CI'-1 ( , - I?-?. q 315?"
L� ❑ Is there evidence that the seal is at least 18 feet long?
VEl Do the well site set-backs appear to be appropriate?
Comments '`--' .a :, s-we ( � (ter.
ass ❑ Fail Inspector ` Date cl II 1)-1
This form m scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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