HomeMy WebLinkAboutWEC2022-00102 - WEC Application - 6/27/2022 _ _____
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MASON COUNTYzy "4 "STREET, SHELTON,WA 98584
ELTON:360-427-9670, EXT.400
(- " COMMUNITY SERVICES 2 7 2. II LFAIR:360-275-4467, EXT.400
juN ELMA:360-482-5269, EXT.400
Building Pla nn ing,E nviron mental 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 22—%5S95 2. Attach a plot plan and vicinity map.
2PZ2-00\01 0 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 \�21`22- 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant I Parcel Identification 11 ' y+
Site Address /h f$/l of l�•-7,l 5'1 s i -- Start Card# !,// y t r 11 f
Drilling Firm C�alae,c 9-pp- Or-,.o I I ,,'tr - "`l -, Phone all - 3O ydL'Jf
Applicant Si.,scc.Yl _Tj2Pfl.j 1. Phone,7¢77p -9 2I//
Mailing Address J % .2 vi/l‘" 97 r--h S`
City 56' ,)-1-/t State LL -'/ Zip 9g))
Parcel Number 2c2c2I615—C± e2p/,,,3
Directions to Site
Is the well site within 100 feet of salt/seawater? ❑Yes
If yes, a variance from DOE is required. Have you applied/received (circle one)a variance? ❑Yes SEEN
NOTICE:All proposed co •: ons to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
Water usage restricts.• . • additional f s may apply to all new wells drilled after January 19t", 2018 per ESSB 6091.
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Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)YES NO TAG# Called In i t (1 Li it-c-02._ /t'( Is/1-z_
❑ ❑ Driller on Site?
❑ ❑ Is the well capped and Vented?
❑ ❑ Is there evidence of a surface seal?
❑ El 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?
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments PJor :L1 ';Pec-ii
El Pass ❑ Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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