HomeMy WebLinkAboutWEC2022-00160 - WEC Application - 11/16/2022 0 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670, EXT.400
COMMUNITY SERVICES
BELFAIR:360-275-4467, EXT.400
Building,Planning,Environmental Health,Community HealthELMA:360-482-5269, EXT.400
FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information
Instructions
WEC 1. Complete Part 1. Incomplete applications will be rejected
.G ^C Receipt Number al ' 2. Attach a plot plan and vicinity map.
2� Vffi❑ Cash 3. Submit this completed application with ap
propriate fee a minimum
Check
/ l of 24 hours in advance of initiating well construction. Refer to
Col l (v Date of Payment LAIC a"' Mason County Environmental Health 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/Parcel Identification
Site Address /J i(7 4/. Ash/a,,.)- 5/l A I .Cr Start Card# /2/4.5,,,349J
Drilling Firm aidfoli—e. e,--- '. h c�
Phone -k --
Applicant olti"E' .0 4-'42—
Phone (.. 19 _�26-5- j /-
Mailing Address s ,� -e
City
State Zip
Parcel Number 3 .=Q 7/ e-3 ) g toe,Cr7
Directions to Site .,ji--/ e `v,� •
Is the well site within 100 feet of salt/seawater? ❑Yes 2' i
If yes, a variance from DOE is required. Have you applied/received (circle one) a variance? ❑Yes 9{dt5
NOTICE:All proposed connec s to new wells am subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
Water usage restrictions ihbnat 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#
Called In
❑ ❑ Driller on Site?
0 ❑ Is the well capped and Vented?
❑ ❑ Is there evidence of a surface seal? _
0 0 Is there a 2"annular space on all sides of the casing? l� I N Y^
❑ ❑ Has the seal slumped?
0 ❑ Is the well flowing or is there evidence of other leakage? NOV1 6 2022ril
0 ❑ Is there evidence of cascading water?
❑ ElIs there evidence that the seal is at least 18 feet long? By
❑ El Do the well site set-backs appear to be appropriate?
Comments
❑ Pass ❑ Fail Inspector
Date
This form may be scanned and available for public view on the Mason County Web site.
Revised:2/7/2018