HomeMy WebLinkAboutWEC2018-00042 - WEC Application - 3/15/2018 �,c rt,_
' MASON COUNTY p Ecz E I)
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tow.- 'A COMMUNITY SERVICE D
f_ ��; LIAR 5 2010
4!�1 a Building,Planning,Environmental Health,Community Health
02
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 DECOMMISSION A WELL
Permit Number Payment Information Instructions
�`� g 1. Complete Part 1. Incomplete applications will be rejected
WE Receipt Number —2. Attach a plot plan and vicinity map.
/6 t111 ❑ Cash 3. Submit this completed application with appropriate fee a
Check minimum of 24 hours in advance of initiating well
31t� (.7 decommission. Refer to Mason County Environmental
0 Date of Payment IA Health fee schedule for cost.
j 4. Mason County Public Health must receive notification at
least 24 hours rior to the decommissionin of the well.
PART 1: Applicant/Parcel Identification Site Address 5 ' E. G •OA/g61/$7 Alp .4L2-yN Start Card# W 35 q 15LQc\
Drilling Firm J<7VAp 7 &/at/do— P one 340. 9Z7- 8/79
Applicant /v/ A---Sevri/ Phone Z53 • 380•SZzf
Mailing Address giZO E, . /Z BOZ City 3Ei.. 4-/AG, GUI State al— Zip p '5"Zg
Parcel Number /-2Z3Zl09 ZA//D
Directions to Site S23/ /24 V/Ex; Loop / / E Ceery as7-�,.
Is the well being decommi sioned to allow siting of potential source of contamination (ie. septic drainfield)? ❑ Yes ZNo
If yes, a varia ce from is req 'red. Have you applied/ received (circle one) a variance? ❑ Yes ❑ No
Applic /Agent ature
PART 2: Health Department Review (Staff Use Only)
Iti304,,ck
YES NO TAG# Called In 1
❑ Driller on Site? 5'� �l�'ti1-1PCtri
El El Has the well been decommissioned in accordance with WAC 173-160?
n ❑ Is this a cased well?
❑ ❑ Is a well report available that shows a surface seal?
Method of Decommission 3b bags 0- b.0t..A!-¢-
and Comments Uo� � 1At;;Atan
Pass ❑ Fail Inspector /,_11/L C,� ,�
, -__-_4 L , t\ Date City, IC6
This form may be scanned an ailable for public view on the Mason County Web site.
J:\EH Forms\DRINKING WATER FORMS\Drinking Water Notice of Intent to Decommission a Wcll.docx Revised: 1/20/2017