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HomeMy WebLinkAboutWEC2021-00111 - WEC Application - 5/14/2021 1.6/2021 08: 13 2535148500 JAMES GROUP PAGE 03/04 415 N 6TN STREET, SHELTON,WA 98684 MASON COUNTY SHELTON; 360-427-9670,EXT. 400 '(i. COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400 ELMA; 360-482-5269, EXT. 400 • • Building,Dlannlnp,Envirnnmontal Npaltb,Community Hwhh 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,A- �� 2. Attach a plot plan and vicinity map_ © Cash 3. Submit this completed application with appropriate fee a minimum Check of 24 hours in advance of Initiating well construction. Refer to Mason County Environmental Health fee schedule for cost_ Date of Payment 5 H a ( 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 J757`ezyrl'K. `t)EPm1"/fi 1/Kettive tart Card # +fit= `t`t 0 � Drilling Firm /71t?/G4/A/e Phone Y40 ` / xl Applicant P,9TR/C AZ/ el c7i°i/I Phone.2,51' Mailing Address a y 5 j/ --r 52 > e City State L-t/l4 Zip Parcel Numbers .� 3-0 & QO Directions to Site 5 2 `/ifr-147 ----Z-2 Is the well site within 100 feet of salt/seawater? Dyes KNo If yes. a variance from DOE is required. Have you applied/ 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 usag ' s d 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# -3K 61t4y7 Called In -�/4 21 ,24+12-4 ❑ Er Driller on Site? „�_ t-►��-{ ❑ Is the well capped and Vented? (1 1(2 t r't g)2( [r.}� ❑ Is there evidence of a surface seal? ❑ Is there a 2"annular space on all sides of the casing? ❑ Lly Has the seal slumped? n __ ❑ Ind Is the well flowing or is there evidence of other leakage? 4 7` Z S ` ((J 1 LZ.c15 c 6,/Cv ❑ Is there evidence of cascading water? &I/ El Is there evidence that the seal is at least 16 feet long? iJoT-0 35t)Rvk7b ❑ Do the well site set-backs appear to be appropriate? Comments ' t 1v RCA IJ(0041)EX.Ch.) PL-06 .c6 ftvskt T7rt& TO, y 1 Y /t gC.I--a<AI)e TkPass ❑ Fail Inspector i 44 2f., / i c Date 5I/a This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018 t6/2021 08:13 2535148500 JAMES GROUP PAGE 04/04 a d ,0 ♦ - N 4 i p C a" ; i w gLi.W aleR fl W ( I% lik J ^N a o II Et - I. co cicg ifs 1 c 11 Hill] 00'oSa ��, ��,.,,. \\\\\\\ \\\\\N a D , i 6 i ...-..--kisyzn;N. '' = . . O w 1 „- 009G cc H t` a K ^ v.' „w� - \\ ,op'osz \S.\`\� l $ �,,`�*1 \\\\\\\ o O IR/i. V/.s':%./i:`d'el % \ % ).s' AN‘Y,� Y\YY ••• O CD rn S. ` oYY�Y`Y Ili d Y Y \\ ,00-0Sz \ 3N17A,.LzedOad 0 urJwo., L ` � p