HomeMy WebLinkAboutWEC2021-00017 - WEC Application - 1/21/2020 r / N4ci MASON COUNTY 415 N 6H STREET, SHELTON,WA 98584
iiii, ELTON:360-427-967Q,EXT.400
COMMUNITY SERVICES BELFAIR:360-275-4467,EXT.400
`?, , .) ELMA:360-482-5269,EXT.400
t-4'/ Building,Planning tOWOO neBaa Health Community Health FAX 360 427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
l - r I 1. Complete Part 1.Incomplete applications will be rejected
WEC Receipt Number ''t 2. Attach a plot plan and vicinity map.
it .)--a-1 .. 0 Cash 1 t� 3. Submit this completed application with appropriate fee a minimum
c � 1� Check of 24 hours in advance of initiating well construction. Refer to
d3�1 Mason County Environmental Health fee schedule for cost.
Date of Payment o�j 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 (04 Iklc �Ct JOC.yi t- ) ( 0 Lc Start Card# /V Li_2 3 .—
-
Drilling Firm ''�;rrc::%ate;.:t c'/.. OA ,`/t t'yy= ._T�`-1.e . Phone .3 4ce7-. S .-C �;v'��
Applicant r• Phone t) 9 i 2
Mailing Address 7-:2Z 340 A .„-it .
City Se,—1 . } e State `\ Zip ‘-1---j / 1/r7
Parcel Number t Z v-1`'1 - cat CS uLZ
Directions to Site F(c.\,A S--t" ?T i illy T>rs n ortfb E: fFkci_er t, 7Xj r..A)t"J>i t r c t t ,U. - O�'1TL
`-7 eAz L (_l.cte_Ct,x'Cu� 11el- 9k G.-10j rs�
Is the well site within 100 feet of salt/seawater? Oyes JlNo ^� .,c
If yes, a variance from DOE is required. Have you applied/received (circle one) a variance? :Yes LSO
NOTICE:All proposed connections-to new wells are subject to water adequacy requirements at time of building permit per Mason County Trtfe 6.68.
Water usage restrictions arfad`di`tiioonal fees may apply to all new wells drilled after January 19Ph,2018 per ESSB 6091.
Applicant/ gent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In `)1'2 I_Z1 rrfz `-(/i PA
❑ ❑ Driller on Site?
❑ ❑ Is the well capped and Vented?
❑ ❑ Is there evidence of a surface seal?
❑ ❑ Is there a 2"annular space on all sides of the casing? rmv. TF5:77,77,1.
❑ ❑ Has the seal slumped?
❑ ❑ Is the well flowing or is there evidence of other leakage? °��� `2
202�
❑ ❑ Is there evidence of cascading water? BY-
•
0 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 A-4-'-‘ I N`. P a c--- -is
❑ Pass ❑ Fail Inspector 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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