HomeMy WebLinkAboutWEC2021-00152 - WEC Application - 7/30/2021 (2) I '
'� 415 N 6T"STREET, SHELTON,WA 98584
,, MASON COUNTY SHELTON:360 427 9670, EXT.400
5 '1l' .t COMMUNITY SERVICES BELFAIR:360-275-4467. EXT.400
\` --- . / ELMA:360-482-5269, EXT.400
\Si_ Budding,Planning Environmental Health,Community Health 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 l"y ) 2. Attach a plot plan and vicinity map.
ma`c l . ❑ Cash 3. Submit this completed application with appropriate fee a minimum
P`� �` _- Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
O 1 Date of Payment �1 �d� 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant I Parcel Identification _ f J_ /�f' �{
Site Address q 5/ ��a ke,(s VU CJ c' RUh COStart Card # Log q 72 32
Drilling Firm ro...✓-t r .)\S �''i 1(i Phone 3(hO8O/ Y3/5
D
Applicant L' I i�Z ((.e.r Phone 3(pO /Oco(Y2
Mailing Address .3(--(0 nF 1J1 S F (x,, t Rd
City Be,J-cGLir State (oa_ Zip gg-52=z,
Parcel Number 32v 1 0 r-3 i - On 1 0
Directions to Site
Is the well site within 100 feet of salt/seawater? ❑YesNo
If yes, a variance from DOE is required. Have you applie /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 19th, 2018 per ESSB 6091.
Applicant/Agent ignature
PART 2: Health Department Review (Staff Use Only)
YES NO ATAG# Called In 3� -2-t �� 3l z-t_
❑ Driller on Site?
Er.,,,.- Is the well capped and Vented?
❑ Is there evidence of a surface seal?
[]� E .Is there a 2"annular space on all sides of the casing?
❑ Has the seal slumped?
❑ 1:1.- 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?
Comm is M1 , ') 55(, 1 - I a-3 .o 3cj1 c' 6 1p,.1S IJe- -'%ow<_bC.
Pass ❑ Fail Inspector Date /10 f 2
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/20I8
Mason County WA GIS Web Map
•
r r f '�
I�`�.
r� f/ � J,r'��
/
/ / ,4
//
/ �`�, r4
. ._.._ . ._..__._1 ---
/ / ,,.,_.:NN..,. _
t 4
/ i f
t w - r\\\\\\*\-----
•
\ k.
\
\\ . .
\\
1 /
/1 /7-----7.--------
1_i f/ \ t
/ I
r,: \ ! ;
7/24/2021, 5:14:15 PM 1:6,141
_ 0 0.05 0.1 0.2 mi
L� County Boundary I r I I ` ` t
0 0.07 0.15 0.3 km
---'' Tax Parcels (Zoom in to 1:30,000)
Sources Esri,HERE.Garmin.Intermap,increment P Corp..GEBCO,USGS,
FAO. NPS, NRCAN. GeoBase, IGN. Kadaster NL. Ordnance Survey Esn
Japan.METI,Esri China(Hong Kong),(c(OpenStreetMap contributors.and
the GIS User Community
Mason County WA GIS Web Map Application
Richard Diaz I Esn HERE.Garmin.FAO.USGS,EPA.NPS
m
r
r
7 \
*1
A ♦ 0 0 0
0 �0� 7 O
O �� I`'1 �G �`
ti(t`
O co �0
rn A '0.e...
N
\� A �t�. \Q„ • ( /3 \ \
(..a,
......,,„
con z_
leolk
` N
,r _ \ ,0 \
\ 7�, \
0 tvivi \& \ 7 ill >
-/+,86
O w
m IJ 70
O
m
. 1
0/nnoO'moW°`.` , ��\"
r.
�•S •`'I N = - moC “ Q o -{ O Om ° 00098NSte
� ' D m1 > �/ .,e,..." V N > -. 0 > m � m> DA r8 8 '4
/ �
j�
CSC mO Tc Z WOmZDmmm < n0C mm mIooS Ornrn ° rm O "QSW morn � � O
1 r N -� r D — ,n � C
N mpni rnZ � 000 `" C i > _ oDo rm > r �
(� -0 - nODn r = mmm -- � 7cz _0m
„ OZ yow • al ODD II „ p NOD Gn D � 4
0 Z < m � K t� 3oC DDr Z m -
Dm OmI c, mm CAZXIX) 1Pym 0 0n
ni mom � OD % OcD -, ZDmo c = D
4, � � T �Orn � � , - 0OOm 0Z2 > , 2
0
� z 0 OmQrg OZ 0 � -=+ mom m
m
� DOrn izil �
N r CL) i n oD Op 0 -13
mm _i Co — '� O
� 3 'i � � c - � N
D DD m D6 n
r 4r0D O COOI O � i - m „ Z
m O m om O0 .P M r > mOK
rm -12
ZC T •m • Z -, O CO r0 O Z ( m -9v
o � 0D7 = rnc O, m o
m m y
Z O — Z m o
A D -a Ft n
N `_ m - Ao m o 13 c
z uA Z _
>
Zm rn u,
m > n
rm
r—
_ rn � N mm T
X _ N m ,p cn —
T
N 5
1 < y � cc, OoQ W
9' - m 0 dm Irv)m
z T z (n nIT'rnOo D o _ rn
-1 _ ZOV, -1m rn o x
o _Z N o
CA N N 0
N -1
m
o z
0