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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