HomeMy WebLinkAboutWEC2017-00116 - WEC Application - 11/27/2017 MASON COUNTY
. 41 COMMUNITY SERVICES
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 I 2. Attach a plot plan and vicinity map.
fl ao. l 0 Cash 3. Submit this completed application with appropriate fee a
!Check - i minimum of 24 hours in advance of initiating well
3 I 1` + construction. Refer to Mason County Environmental Health
Date of Payment'a( )I i) t 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/Parcel Identification �W
Site Address Z- f nson la-Dr Clkii.svn I#. 5 r�fr / ) Start Card# 3 c9 (Sc ✓
Drilling Firm Kip "br,'1I:n9 EitC.- Phone (,aJ 612—f.-g
Applicant �,'J Ne,•k)ei Phone
Mailing Address .c2z g U,r•.,po,•nt re) Nu-)
City OT,`8 u�.rb / State j - Zip 4 c221r
Parcel Number 22.-tip rm - Clam/S`--
-T-4(/.ce- l (—?rorn Pit. )At%7M..•e •nL4) Eel-son tom-e4J• gee Pen 'EmrS►n ,K. , on,,, go,
Directions to Site 2e.o4.. •E 1r14en Red 15enle) Zn inn Te,en'4.,t.-, -Wee_ Sern,v) T aenson t k'Di 4 1.1or.
Is the well site within 100 feet of salt/seawater'? Dyes No 'drops its on "r,ta tr a7ayc-oNe 1/S045 g4- .Pror4 �}.reno .
If yes, a variance from
sDOE is required. Have you applied received (circle one) a variance? Dyes ❑No
Applicant/Agent Signre
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In '1-3 ---c=8 —` ` " t
❑ "fR, Driller on Site? r hQh1c-A- c jt 4\1; (2(
❑ ElIs the well capped and Vented? , C- (1(2-1
A ❑ ❑ Is there evidence of a surface seal?
0 ❑ 0 Is there a 2" annular space on all sides of the casing?
0 ID Has the seal slumped?
o 0 0 Is the well flowing or is there evidence of other leakage?
' 1❑ ❑ Is there evidence of cascading water?
P ❑ 0 Is there evidence that the seal is at least 18 feet long?
0 0 Do the well site set-backs appear to be appropriate?
Comments (-'44,1,L.r.Z\ Iry 1,ro PUS y• >-NIs('E6-1—C72 orc v'T ra s'(7Z 7 Ai Cs P12E$Fiv i >5i1 r nla-r s rfi e rEt
0 Pass ❑ Fail Inspector l?Ic R l✓c i i'2 T -rlie cf-J o4"G61) �,,i-,tr-Date ,:z(1 z ' Ajor
This form may .e scanned and available for public view on the Mason County Web . i ni56ie.-TEA
J:\EH Forms\DRINKING WATER FORMS\Drinking Water Notice of Intent to Construct a Well.docx Revised: 1/20/2017
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PRE-LIMINAR1 PLAN:
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NOT APPROVED DESIGN
INSTALLATION DESIGNER SIGNOFF/ASBUI LT FEE WILL
BE CHARGED AT TIME OF INSTALLATION
PIONEER DIGGING, INC. CUSTOMER: DAVE NEUFER
PARCEL#:22103-50-00014&15 SCALE 1:40
SEPTIC DESIGNS ADDR FSS: 280 BENSON LK RD
3083 E MASON BENSON RD. GRAPEVIEW,WA 98546 DESIGNER: ROBERT PAYSSE
OFFICE-360-426-1803 FAX-360-427-2353 DESIGN PAGE OF