HomeMy WebLinkAboutWEC2021-00051 - WEC Application - 2/19/2021 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON: 360-427-9670, EXT.400
_1 a COMMUNITY SERVICES BELFAIR: 360 275 4467, EXT.400
ELMA: 360-482-5269, EXT.400
Budding,Planning,Environmental Health,Community Health
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 L 4 OM 2. Attach a plot plan and vicinity map.
/� ID Cash 3. Submit this completed application with appropriate fee a minimum
r'"'� `6p Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
��� ' Date of Payment nn"l 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 355 E Happy Home DR. Belfair Start Card# WE41218
Drilling Firm Nicholson Drilling Phone (360)876-4421
Applicant Ammon jevisen AA��44 --11 Phone (3 O) CZN- 5a'
Mailing Address _ZO37 Z. Am oil CO1►'� N uJ
City Poo 1,5196 State WA Zip 6f'77 0
Parcel Number 22223-32-90169
Directions to Site see attached map
Is the well site within 100 feet of salt/seawater? ❑Yes No
If yes, a variance from DOE is required. Have you applied/ received (circle one)a variance? []Yes No
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 usage restrictions and additional fees may apply to all new wells drilled after January 19th,2018 per ESSB 6091.
went Signature
PART 2: Health Department Review(Staff Use Only)
010 YES NO TAG# &t114 (03$ Called In ( ' Fo-(Z— -(1 I ZA
❑ Driller on Site? Cth At. be -ro 3 / "S J 2- I
l^-/ ❑❑ Is the well capped and Vented?Is there evidence of a surface seal? I-f *I"-
l.Z ❑ Is there a 2"annular space on all sides of the casing?
❑ [1/ Has the seal slumped?
❑ P" 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?
[K ❑ Do the well site set-backs appear to be appropriate?
Comments 91, $ 1't)-% i - I-')-•9O1198"
ass ❑ Fail Inspector _ Date 4 it.17- 6
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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