HomeMy WebLinkAboutWEC2022-00159 - WEC Application - 11/10/2022 415 N 6TH STREET, SHELTON,WA 98584
MASON COUNTY SHELTON:360-427-9670, EXT.400
rf"7 COMMUNITY SERVICES BELFAIR:360-275-4467,EXT.400
ELMA:360-482-5269,EXT.400
217 Building.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 2. Attach a plot plan and vicinity map. fee a minimum
'1 ((��� �j� 0 Cash 3. Submit this completed application with appropriate
Xa-Z-"65 f'I Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment 1 ll b j aa. 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/Parcel Identification 11 /
Site Address /5-9 7 6 T /2/- 3�-"2` Start Card# i,f ,'51.Q33
Drilling Firm e [Slto iLv� v�'� - pr. ` I i ',,
Phone 36,a-.-30- %wc04--
/
Applicant C �I 6'r" d / / J 1.-"{1' Phone 2S. - /3
Mailing Address /9.t /3 0d�'S
City Co 1/-a/,-) State A r Zip 5-f f/, 3
Parcel Number J a_ ,.;Z S - l - to 9 0 r I
Directions to Site • t U
Is the well site within 100 feet of salt/seawater? ❑Yes
! o C7�
If yes, a variance from DOE is required. Have you applied/received (circle one)a variance? Oyes I o 1
NOTICE All osed conn tuns o new wells are subject to water adequacy requirements at time of building permit per Mason!
roCounty-Title o 6.!8.l
P P "
Water usage restrictions d a • nal f ay apply to all new wells drilled after January 19th,201 S per ESSB 6091. I ry
I
-Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# ---
Called In i(22.42 3 r'F-'e 212_9
❑ ❑ 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?
El ❑ Is the well flowing or is there evidence of other leakage?
Cl ❑ 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 tJ,'r I Ni 5 e e Crtc--6
❑ Pass ❑ Fail Inspector
Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018