HomeMy WebLinkAboutWEC2023-00091 - WEC Application - 8/7/2023 415 N 6TH STREET, SHELTON,WA 98584
MASON COUNTY SHELTON: 360-427-9670, EXT.400
‘17'"-IJ COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
ELMA: 360-482-5269, EXT.400
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 Numbert03'0353?), 2. Attach a plot plan and vicinity map.
(21. ) ❑ Cash 3. Submit this completed application with appropriate fee a minimum
Check of 24 hours in advance of initiating well construction. Refer to
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Mason County Environmental Health fee schedule for cost.
�'lDate of Payment l 2.,--34. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant I Parcel Identification .
Site Address ' 9 I. NS B tikaksm)+h Dr. Start Card# W E 5 gq 7 a 3
Drilling Firm R 1 ChafillSen We 11 1;c 2O • Phone MD 53 4. M Z
Applicant Ptfevnk. A . 414-eS4474 / `a,1 e M4 RAN la Phone 66 . • - 0 l )
Mailing Address 5 o'�'� //Until,J )..n. T1�v
City /U ,t State VIA Zip 9 938 6
Parcel Number a 2310 - ,q_ 964103
Directions to Site I �{- Bar!.f'tck. - 'Q �(�. q, - Pa„ /Pas Forge--) Z'
t a ea! t 117We0) briVetaUf 41 .
Is the well site within 100 feet of salt/seawater? ❑Yes XINo
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 19', 2018 per ESSB 6091.
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Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)
i
YES NO TAG# Called In '1l g/2 3 F&R qJ24 /2
❑ ❑ Driller on Site?
❑ ❑ Is the well capped and Vented? .D
❑ ❑ Is there evidence of a surface seal?
G
❑ ❑ Is there a 2" annular space on all sides of the casing?
❑ ❑ Has the seal slumped?
❑ ❑ Is the well flowing or is there evidence of other leakage? • .:i
❑ ❑ Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long? `by
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments AJO7` i A/5 PCc:-rE 2
❑ Pass ❑ Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/20 1 8
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MASON CO)NTy ENVIRONMENTAL HEACT:
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On-Site Septic ROC Name: Marcinko Tax Parcel: 22310-79-90663 �1
PIL LIEQ` Scale = 1" = 40' Address: 797 NE Blacksmith Dr, Belfair f �41 c/./1."!16 i•
r 0Eq ��+ This is not a survey:all property lines/boundaries have been demonstrated by the Uvrner(s)and/or their Agent(s). '�!�/• r .t
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Dn Site Septic Design I Allied Septic Design and Excavating i 20100609 ��,11
J. 0 Frank A.Marcinko
i LICENSED DESIGNER 1