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HomeMy WebLinkAboutWEC2017-00115 - WEC Application - 11/27/2017 MASON COUNTY $' COMMUNITY SERVICES 4 g/ Building,Planning,Environmental Health,Community Health 415 N 6th Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 ❖ Elma: (360)482-5269 ext 400 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. 'a0 I r� 0 Cash 3. Submit this completed application with appropriate fee a 1 -Check minimum of 24 hours in advance of initiating well C' Iconstruction. Refer to Mason County Environmental Health Date of Payment t 1 ' fee schedule for cost. 4. Mason County Public must receive notification at least 24 hours prior to the drilling of the well. PART 1:Applicant I Parcel Identification Site Address t.8410.'x:15e.i/ Dr t il•r•z,i /A Start Card# f,J j Drilling Firm hrlr).'? , i I,s1,16 fin( . Phone (36.4) c./7 Applicant u, o° � � ) �'f Phone — o Mailing Address 777t (l;e City Gt t cj' :t'}tZ� State Zip C1 Parcel Number Z 2/CD 3— —00 S`iv�111C, Et„e -) Pe.,-,r. t�t(d 'E Iri t& , 4. .�te et-t #ye*?cr, t d�? i_f4,lad Directions to Site u,n;,I yn0 p.=r,I L_. F 5(f&,&- 3 l 2nAtf*:i.e87. `7'.:4'n TL.Ak/. T-ts/[ r Is the well site within 100 feet of salt/seawater? Dyes iv No ��.. {o SC, E Beti5cel/.t4e. . uic C49. ?cape,40 If yes, a variance from DOE is required. Have you applied/received (circle one) a variance? Dyes ❑No oo: r.,k Appcix ►/ic4p1 e'/rr'r1bii SIGH° i c't:0r1 Applicant/ gent Signature "j :r1c0 PART 2: Health Department Review(Staff Use Only) YES NO TAG# Called In tsS Z 1 ,rc-re ZI l4 � Zt ❑ ❑ Driller on Site? ❑ ❑ Is the well capped and Vented? ❑ Cl Is there evidence of a surface seal? 0 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 Itl©7' fn!S PEETE* ❑ Pass ❑ Fail Inspector Date This form may be scanned and available for public view on the Mason County Web site. J:\EH Forms\DRINKING WA1'hR FORMS\Drinking Water Notice of Intent to Construct a Well.docx Revised: 1/20/2017