HomeMy WebLinkAboutWEC2023-00020 - WEC Application - 2/13/2023 415 N 6T"STREET, SHELTON,WA 98584
MASON COUNTY MOM7Mr, SHELTON:360-427-9670, EXT.400
gr"--111 t COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
ELMA: 360-482-5269, EXT.400
Suiting.Ptamnq nm u
Ennroental Health.Conanrty Health
F E B 13 2023 L FAX: 360 427 7787787
BY:
NOTICE OF INTENT TO CONSTRUCT A WELL
---------------
Permit Number Payment Information Instructions
^� 1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number .4c - 2. Attach a plot plan and vicinity map.
cg3' El Cash 3. Submit this completed application with appropriate fee a minimum
•Check of 24 hours in advance of initiating well construction. Refer to
/ Mason County Environmental Health fee schedule for cost.
Date of Payment al o cz 4. Mason County Public must receive notification at least 24 hours
bb prior to the drilling of the well.
PART 1: Applicant/ Parcel Identification h I"
Site Address 0 `--1P VLL,C ` teA 12,,I V( Start Card# 1/UE 'j 1 ,e�,D--"
Drilling Firm 7 l/Z tz a ! tcc,t Phone - &d .4 7 7 -77 2�
NI
Applicant I 412,.4' 6 kt .-.`T�i L-` ' lv't Phone '3 60 7 4 ) -- a 3 4-4 S-
Mailing Address .(o f J t -z vu t1--a>7 i►`i"
City ' State Let) r1 Zip -1 S- S 3 .�
Parcel Number ) - �4 - _. e e 1 o
Directions to Site k.),4 '3 1 4 . viA t I1 S; 5 r t F 1 5 o- i--- - -5 f ad T3 rl t
Is the well site within 100 feet of salt/seawater? ['Yes ISNo
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, sage res rictio and additional fees may apply to all new wells drilled after January 19`^. 2018 per ESSB 6091.
all4l,t 4 -T1't-' / Of
Applicnt/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In -2-12LP(2- �,,41. ?(2-' 113
❑ _ET Driller on Site?
❑ Is the well capped and Vented?
Ji" ❑ Is there evidence of a surface seal?
❑ Is there a 2"annular space on all sides of the casing?
Sa" ❑ Has the seal slumped?
❑ Is the well flowing or is there evidence of other leakage?
❑ Is there evidence of cascading water?
El ❑ Is there evidence that the seal is at least 18 feet long? N e'Se- Je-6
111 ❑ Do the well site set-backs appear to be appropriate?
Corn is 4 i>J -c k 6 NM- "brt Ni i l''Ct t)
Iltass ❑ Fail Inspector ph Date . (((1Z3
This form may be scanned and available for public view on the Mason County Web site. Revised:217/2018
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