HomeMy WebLinkAboutWEC2021-00015 - WEC Application - 1/19/2020 it,P
#' '^�w 415 N 6TH STREET, SHELTON,WA 98584
/ `� MASON COUNTY SHELTON: 360-427-9670, EXT.400
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'I I- COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
-�— ELMA: 360-482-5269, EXT.400
`\\\ ,i'V Building,Planning,Environmental Health,Community Health 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 c 2. Attach a plot plan and vicinity map.
c;c3a I.- 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.
> [F3 Date of Payment 1 tl I,1 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 202 SE Mermaid Lane Start Card# WE42183
Drilling Firm Moerke & Son' s Phone 360-748-3805
Applicant Kevin Kerr Phone 206-248-0900
Mailing Address P.O. Box 1429, Shelton, WA 98584
City State Zip
Parcel Number 22029-50-00013
Directions to Site Off of Lynch Rd, then Arcadia Shores Rd, end of Mermaid Lane
Is the well site within 100 feet of salt/seawater? ❑Yes ANo
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 additional fees may apply to all new wells drilled after January 19`",2018 per ESSB 6091.
Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)
YES NO TAG# -7D6 7 7 3 Called In at312-t foil- S1&,jyl 1Ant
❑ ,❑ Driller on Site?
Er ❑ Is the well capped and Vented? r
ram"
' ❑ Is there evidence of a surface seal?c` ? 1 -' 1 V'
k1 ❑ Is there a 2" annular space on all sides of the casing? fC{ J 1
Has the seal slumped? A ' 1 9 202
El
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Is the well flowing or is there evidence of other leakage? BY _
❑ [r Is there evidence of cascading water? ..`'---
❑ ❑ Is there evidence that the seal is at least 18 feet long? 'N - 0 W'- t ��
❑ Do the well site set-backs appear to be appropriate? i ZZ ' s S'(=, 2;1-1
Comments
D Pass ❑ Fail Inspector v,-) --ki, Date ?//(/
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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This map/plat is being furnished as an aid in locating the herein described land in relation to adjoining streets,
natural boundaries and other land,and is not a survey of the land depicted.Except to the extent a policy of title
insurance is expressly modified by endorsement,if any,the company does not insure dimensions,distances,
location of easements,acreage or other matters shown thereon.
• LAND TITLE COMPANY y4--
LEAt RSHIP•TRUST•CQMMITMCNT
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