HomeMy WebLinkAboutWEC2022-00161 - WEC Application - 11/18/2022 ,�1 7.s- cc
6TH STREET, SHELTON,WA 98584
MASON COUNTY 415 N SHELTON:360-427 9670 EXT.400
t II' ' COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
.,: �-- s. ELMA:360-482-5269, EXT.400
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om`�4,7 Bulking 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 Number ' cE�1 '6-11S(# 2. Attach a plot plan and vicinity map.
D Cash 3. Submit this completed application with appropriate fee a minimum
rjSCf — -. Check of 24 hours in advance of initiating well construction. Refer to
OD RO Mason County Environmental Health fee schedule for cost.
Date of Payment I`{�S�?� 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/Parcel Identification
Site Address ✓was--/ So e,.ii1 4 c:c/ ja'ad• Start Card# (,_iE._.5%.29a
Drilling Firm A_*,�cvrYlovN. 4,ie /./ 4,,s%/...,, Phone -._537- 7.iY Z
Applicant 61-,,,,,,e__ Phone (y//;1s,J-yc:) ?O 7?
Mailing Address 4P.O. 4 p>er /y y.� 7
City <A.CCv".c., State i� , Zip 96`/`/c'
Parcel Number J,Zo25"—SO — E1O Oc' `.
Directions to Site r/O,n 0/ypi,4 , b' )1) 9O f'c,i 71 e.,*-.- ,4t 4 ct, iel 1�4J71p.,ieP�ot, 1-e/T'
dOle"— .Z.coo‘, 4,. .
Is the well site within 100 feet of salt/seawater? ❑Yes No
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 usa estrictions and additional fees may apply to all new wells drilled after January 19`", 2018 per ESSB 6091.
Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)
YES NO TAG# J JI _ Called In t t \Lg F k` (Lq 2-2---
❑ Driller on Site?
❑ ❑ Is the well capped and Vented?
❑ Is there evidence of a surface seal?
❑ ❑ Is there a 2"annular space on all sides of the casing?
❑ ❑ Has the seal slumped? 1:101JZOCEVir7
❑ ❑ Is the well flowing or is there evidence of other leakage?
❑ ❑ Is there evidence of cascading water? Ni NOV 18 2022 L
❑ ❑ Is there evidence that the seal is at least 18 feet long?
❑ Do the well site set-backssJ appear to be appropriate? BY:
Comments C./ 11 11 ). (QC ` 1) ` 9(1 1 Cr r
` ] Pass III Fail Inspector (--j ��� Date
11-.2 --,,,z:
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/20I8
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