HomeMy WebLinkAboutWEC2021-00112 - WEC Application - 5/14/2021 04/16/2021 08: 13 2535148500 JAMES GROUP PAGE 01/04
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• "'"` ;• 415 N 6TH STREET,SHELTON,WA 98584
i ', MASON COUNTY SHELTON:360-427-9670, EXT.400
l' COMMUNITY SERVICES SELFAIR; 360-275-4467, EXT.400
1.,,,:,�'=~-- ELMA:360-482-6269, EXT.400
�,. f} ^', fl Aulldlna.Pining.rnrTenrarrvnlHwaltA,CwnmuniyHealth FAX 360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information T�_ ..-� Inetntstlons
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number 2 ( 2, Attach a plot plan and vicinity map.
a0 Cash 3. Submit this completed application with appropriate fee a minimum
- I. i Check of 24 hours in advance of Initiating well construction.. Refer to
11 I�a Date of Payment Mason County Environmental Health fee schedule for cost.
I��Ia ' 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1:Applicant!Parcel Identification �'C 1 / .� �� � ��
Site Address ?,7-eLA"�gen10 prylLCrg>•6,9 -eglif tart Card# %SC All d J O
Drilling Firm f JIe/ c iu �P/(L/N6__ Phone 8Z V412/
Applicant k 41. i/?2/ Vo'fe1L-,- Phone 3^ 9
Mailing Address '4/G3—d/.1-- 7- .
City / -///7/2. State t-t49 Zip ',e,:-.3,
Parcel Number ______
Directions to Site 5T2 72
Is the well site within 100 feet of salt/seawater? Oyes No
If yes, a variance from DOE is required. Have you applied,I received (circle one) a variance? ❑Yes%o
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((sag d additional fees may apply to all new wells drilled after January 19m. 2018 per ESSB 6091. -
' Applicant/Agent Signature •
PART 2: Health Department Review(Staff Use Only) • • •
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YES NO TAG# i I V 'l . " <' Called in 113(2-1 1-o9-- S114 (LI
❑ Driller on Site?
CD 0 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?
❑ la' Has the seal slumped?
O Is the well flowing or is there evidence of other leakage?
❑ a--^ Is there evidence of cascading water?
0 ❑ Is there evidence that the seal is at least 18 feet long? NE- ic--h, in. 2.51S 0 'g 2..j .( t . 9 40 6 t /
IE( ❑ Do the well site set-backs appear to be appropriate? i
Comments ; S t ,Q-6n✓e 6-IZA-e C, 'f wGr jnl t-"L r"m1cAL i f I rinf6-fouw 4 S 719. k 100646..i-itl v
Ii lass ❑ Fail Inspector ,4� 1LL' Date .5 2-t 1 f ( (a.i
This form may be scanned and available for public view on the Mason County Web site. Reviscd:2/7/2018
04/16/2021 08:13 2535148500 JAMES GROUP PAGE 02/04
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