HomeMy WebLinkAboutWEC2020-00077 - WEC Application - 6/4/2021 1a` 415 N 6TH STREET, SHELTON,WA 98584
? , MASON COUNTY SHELTON:360-427-9670, EXT.400
i' 1 COMMUNITY SERVICES BELFAIR:360-275-4467, EXT. 400
"' `' ELMA: 360-482-5269, EXT.400
,,,, c.,,, Building,Planning,Environmental Health,Community Health
ra,v� 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 as ek 2. Attach a plot plan and vicinity map.
a0a0 0 Cash 3. Submit this completed application with appropriate fee a minimum
F Check of 24 hours in advance of initiating well construction. Refer to
60o171 ��4./2i Mason County Environmental Health fee schedule for cost.
Date of Payment 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 340 E Sherwood Hills S Allyn,WA.98524 Start Card# WE-3$ Lt.
Drilling Firm Home Owner Kerry Woolley Phone 253-222-2178
Applicant Kerry Woolley Phone 253-222-2178
Mailing Address P.O. Box 611
City Burley State WA Zip 98322
Parcel Number i; A-3 0 -7S- j 0 / Y,2
Directions to Site hwy 3 to Sherwood Creek Rd. left onto Sherwood Hills Left onto E Sherwood Hills S
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 connections to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled after January 19t", 2018 per ESSB 6091.
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Applica ,6 Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG # Called In i lc (0/rt12I A-etA.
[ ❑ Driller on Site?
❑ Er Is the well capped and Vented?
❑K ❑ Is there evidence of a surface seal?
E ❑ Is there a 2" annular space on all sides of the casing?
❑ ❑' Has the seal slumped? tsl'i 013Seav'
❑ [r Is the well flowing or is there evidence of other leakage? w!o
❑ E Is there evidence of cascading water?
❑Y- ❑ Is there evidence that the seal is at least 18 feet long?
11;K ❑ Do the well site set-backs appear to be appropriate? 4? “,Z6c I( I - (2-2,•Cg-331'5(
Comments / d RiL,s one e - c`' - "PT' ? "AO' Ff r b BriffiAtiet, SQL fico►vt_ srker
Eg"Kass ❑ Fail Inspector /1 - -•\, Date •; "/12 1
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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