HomeMy WebLinkAboutWEC2023-00009 - WEC Application - 1/23/2023 5 N 6T" STREET, SHELTON,WA 98584
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MASON COUNTY SHELTON: 360-427-9670, EXT.400
! COMMUNITY SERVICES j" 2 3 2023 BELFAIR: 360-275-4467, EXT.400
ELMA: 360-482-5269, EXT.400
Building,Planning,Environmental Health,Community Health BY: 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, 3'b04 5,71 2. Attach a plot plan and vicinity map.
D23-n000G ❑ Cash 3. Submit this completed application with appropriate fee a minimum
F) Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment Ot 123 f�� 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 g�( Aik.1kne_ti Cie)2 V 12-4 — she (-fry) Start Card # t
Drilling Firm kAO�x( Q'Yx SOV\5 ?yaw ()k � y-iA Phone 3110 C " " (r).)05
Applicant , \(kV e_. �:7_ kieap t✓"icul 10( Phone 0- 1-1610 3(00
Mailing Address ( Ma(6(nej (ILIA YZc(
City S1/4,1 e 1 f h State VA,.4k, Zip R f35q-)(-1
Parcel Number 0,").00 l 7 - �j 0 - q 0,DO
Directions to Site
Is the well site within 100 feet of salt/seawater? ['Yes EiNo
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 usage restrictions and additional fees ma apply to all new wells drilled after January 19`n, 2018 per ESSB 6091.
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pplic1 Agent Signature
PART 2: Health Department Review (Staff Use Only)
YES NO TAG # 15I'I S2-3 Called In �' aC f .; Cu-a- Z l2
❑ kf Driller on Site? i
Ja ❑ Is the well capped and Vented?
❑ Is there evidence of a surface seal?
-E1 ❑ Is there a 2" annular space on all sides of the casing?
❑ ,a Has the seal slumped?
❑ Is the well flowing or is there evidence of other leakage?
❑ ...E' Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long? L5 c
❑ Do the well site set-backs appear to be appropriate?
Comments ti7. z-L1g329 , r ( � z - Z `t �
[Pass ❑ Fail Inspector a /ilce ,..) Date 31 24-1 1 2-3
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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