HomeMy WebLinkAboutWEC2021-00161 - WEC Application - 8/30/2021 \\� MASON COUNTY j' ��._., �+ 415 N 6TH STREET, SHELTON,WA 98584
! Le w SHELTON: 360-427-9670, EXT.400
,fig' COMMUNITY SERVICES AUGBELFAIR: 360-275-4467, EXT.400
, ,- i Building,Planning,@nviraimental Health,CommuniryHealth
G 3 0 2021 ELMA: 360-482-5269, EXT.400
v, ^MVO,' 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.
ae 9-l 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.
001Le, I 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 I-1S I E FjV(1o,,,,,dy Start Card # - S7 IS
Drilling Firm (AYc,a►c. 1�f;11;‘.r) mac. Phone 3(L0- (42,L -33'S
Applicant -g;(\ lk)c—ktS Phone ZO(o- ciS'- 1-j58-
Mailing Address To -,o,c V to
City 1,,Q.A1/4,,„_ State lJ..)c, Zip ( `t
Parcel Number 7-2D3(Q - 24 - 00000
Directions to Site collovJ -}0 ok 8u,c5_I 5$i. co -(2-33Z`l') Tot1oZ {n o..Adrtss
Is the well site within 100 feet of salt/seawater? ❑Yes p-No
If yes, a variance from DOE is required. Have you applied/ received (circle one) a variance? ['Yes ZINo
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 u age restrictio s and additional fees 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# 11`1X (SAS Called In i///Zi 7f7/zi
❑ 0 Driller on Site?
a ❑ Is the well capped and Vented?
E Is there evidence of a surface seal?
f. ❑ Is there a 2" annular space on all sides of the casing?
❑ 0 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? ' ` t: 7251442-46
a- ❑ Do the well site set-backs appear to be appropriate?
Comments 97 1 'G -1 5 S- - j L Z,_c( S. 0 2-1
[ }Pass ❑ Fail Inspector `1/ ti Date ` 7
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018