HomeMy WebLinkAboutWEC2020-00198 - WEC Application - 12/15/2020 PI L fi.S,�;l� L:t.
�i �5 415 N 6TH STREET, SHELTON,WA 98584
Fp MASON COUNTY �� � SHELTON: 360-427-9670, EXT.400
__1 '. COMMUNITY SERVICES; t t BELFAIR: 360-275-4467, EXT. 400
\z �"~ DEC 1 5 2� ELMA: 360-482-5269, EXT.400
'r Building,Planning,Environmental Health,Community Health
<'..ill is'''' 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 2. Attach a plot plan and vicinity map.
Cr61O .- D Cash 3. Submit this completed application with appropriate fee a minimum
0 Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
�C) tqS Date of Payment �ltslar) 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/ Parcelf�''�/t Identification
Site Address y(O RE ,' 643 , ge/4(✓- Start Card # t Ji 41 ; a
Drilling Firm q j c i o/<o 0.e'n t'� Phone 3,6j --S 7 , L I L/2)
Applicant C ((, r_Tpo /-1 f0( 0��► 4, 3
Phone [ f�')-yol 3'79 7
Mailing Address WO - X yote
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1 yg Y
City p :�' State �,/� Zip
Parcel Number ?.5/1 ._ !GQ _- p�I ,)(.../
Directions to Site ,A. 8t G' h yi'ti�/Q �,/L'1�i Ovt 1 J 1" ((f&C f OQt-e
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 c nnections to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
Water usa restri and ad ipnal fees may apply to a new wells drilled after January 19'^,2018 per ESSB 6091.
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Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)
YES NO TAG# Called In ‘(2_( t= 5-12_`t(2_(
❑ ❑ 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?
❑ ❑ Has the seal slumped?
❑ ❑ 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?
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments =`f tti t'i--a= 1LN,
❑ 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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