HomeMy WebLinkAboutWEC2021-00160 - WEC Application - 8/30/2021 \•
415 N 6TH STREET, SHELTON,WA 98584
;\ MASON COUNTY AUG 3 0 2021 c.. SHELTON: 360-427-9670, EXT.400
'I I' 'o COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
i ELMA:360-482-5269, EXT.400
`tq ay i Building,Planning,Environmental Health,Community Health !,
•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 2. Attach a plot plan and vicinity map.
❑ Cash 3. Submit this completed application with appropriate fee a minimum
El Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
G C LUC) Date of Payment 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 2-5o E LtwAbolrc,1 Start Card# v3E, 4555)
Drilling Firm co..C.oVw �r,1\�h c. Phone 3(o - '-{2.443-33ciS
Applicant C-ife.g Mc..co-floonc1 Phone 3(00- (DLO-CZ3Z
Mailing Address ?o �jC)jc fl O
City S\1e 1-\ov. State Zip c S
Parcel Number 12 I Y7 - ly — Ob 11 O
Directions to Site 1rcw. C-�r (,vtep) ko r'el\ Avrv\ NOQ"(1M or• �..oti.�1, �tQ 6- S+k o", Y► —@a er-SS
Is the well site within 100 feet of salt/seawater? ❑Yes SNo
If yes, a variance from DOE is required. Have you applied/ received (circle one) a variance? ❑Yes SNo
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 usag restrictions and additional fees may apply to all new wells drilled after January 19th, 2018 per ESSB 6091.
C6t)v` OltrCactiCk drAt
Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)/ /
YES NO TAG # If . K%C' Called In It C/2-I f `3( (A.(
❑ ❑ Driller on Site?
[� ❑ Is the well capped and Vented?
❑ Is there evidence of a surface seal?
El Is there a 2" annular space on all sides of the casing?
❑ ,B' Has the seal slumped?
❑ Is the well flowing or is there evidence of other leakage?
El Is there evidence of cascading water? B 9
C• ❑ ❑ Is there evidence that the seal is at least 18 feet long? `' t` ', D
CI ❑ Do the well site set-backs appear to be appropriate? -21--0 Qs
Comments ,ti )S f r c w1` E--4l ( PV4 16�
Pass ❑ Fail Inspector fr)4/t. Date 1�
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018