HomeMy WebLinkAboutWEC2020-00121 - WEC Application - 8/3/2020 (iIMIT" -. MASON COUNTY
_ COMMUNITY SERVICES
l Building,Planning,Environmental Health,Community Health
415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 + Belfair: (360)275-4467 ext 400 + Elma: (360)482-5269 ext 400
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 .CG- �Z `")-. 2. Attach a plot plan and vicinity map.
j C) - 0 Cash 3. Submit this completed application with appropriate fee a
-ZIP Check minimum of 24 hours in advance of initiating well
Dula I construction. Refer to Mason County Environmental Health
Date of Payment gi3i60 fee schedule for cost.
4. Mason County Public must receive notification at least 24
hours prior to the drilling of the well.
PART 1:Applicant/ Parcel Identification 1
Site Address 9,j/ �i'����� P li ,�h /'da Start Card# tC/ �/ L�,...,
Drilling Firm ,�f/i//pp 47/i/i _ G', . ,!/G Phone�- e0-" t 2 7"eq/ /4
Applicant j e/,�,�/Yy -r!_N Phone
Mailing Address -S---7 jd 6#2,r L eI (au
Cityf/1it/�- / State /4,1/) Zip ?s5 ii
Parcel Number �j (9/1/4_5' r � - Fe� -'
Directions to Site a)t e/i41Y7 /9 // /c '� 'T/v De'C i /�
Is the well site within 100 feet of salt/seawater? Yes ®No
If ye , ,,variance from is re 'red. Have yo plied/received (circle one) a variance? ❑Yeso
A ica ent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In -1/1 le/z_i Fat 1/2e/2- I
❑ 0 Driller on Site?
LI ❑ Is the well capped and Vented?
❑ 0 is there evidence of a surface seal?
❑ ❑ Is there a 2" annular space on all sides of the casing?
❑ ❑ Has the seal slumped?
❑ ❑ Is the well flowing or is there evidence of other leakage?
❑ ❑ Is there evidence of cascading water?
❑ 0 Is there evidence that the seal is at least 18 feet long?
❑ 0 Do the well site set-backs appear to be appropriate?
Comments -2 c<1 T6-•› sye_s i ZrjA. .s Ybl uS Dec.keTir Ilcet 1 1nc51'Cc--
0 Pass 0 Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site.
J:\EH Forms\DRINKING WATER FORMS\Drinking Water Notice of Intent to Construct a Well.docx Revised: 1/20/2017
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