HomeMy WebLinkAboutWEC2017-00030 - WEC Application - 5/8/2017 (2) MASON COUNTY
( ! COMMUNITY SERVICES
Building Planning,Environmental Health Community Health
415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 C. Belfair: (360)275-4467 ext 400 ae Elma: (360)482-5269 ext 400
FAX(360)427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
Qp 21GI'f• 1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number OI 2. Attach a plot plan and vicinity map.
eki17— 0 Cash 3. Submit this completed application with appropriate fee a
lit Check37ab7 minimum of 24 hours in advance of initiating well
000_70 construction. Refer to Mason County Environmental HealthDate of Payment big-`Li fee schedule for cost.
4. 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 -35 ) 1U6Mh f/WO 640422 start card# lug raw
raa
Drilling Firm PJIL!')oican tutu Dr(fhnc Phone 3(;p -396- 'Ma)
Applicant � £8 n )n'i9 Wl4 Phone 360-a%5. 3419
Mailing Address ,EA( IbQ)
-Be
city l'1-E .6 State u)f) Zip qg SD-%
Parcel Number )(.a01?) ,�—� O_� ,X40,,,,,p I.� 1 L
Directions to Site f)(0.411 -90Yl 1Vwifl vu� 4 d t7 -� ccud awn RUM
Is the well site within 100 feet of salt I seawate Yes JNo
If yes, a variance from DOE is required. Have you applied I received(circle one)a variance? ❑Yes ❑No
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# TN Z-Ly Called In 5-5/to
❑ ❑ Driller on Site? cjn ,i
❑ ❑ Is the well capped and Vented? `JT� V
❑ 0 Is there evidence of a surface seal?
❑ ❑ 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?
❑ ❑ Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long?
❑ 0 Do the well (sIite set-backssI� appear to beI� appropriate? / II pp
Comments Via Goo Steel Gles� of to rah on s1,2c-swi on SIL - (Iah(L,.s.�l b�f p(ah, I14: cJiaa 4
❑ Pass ❑ Fail Inspector /fn�" i✓ISppeG�"Cc( I r ADE /)sdeymewl Date \111)11
This form may be scanned and hvallable for public view oh the Mason County Web site.
H:\DRINKING WATER PROGRAM\2 PARTY FORMS\Drinking Water Notice of Intent to Construct a WelI.docx Revised:
2/14/2017
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