HomeMy WebLinkAboutWEC2023-00006 - WEC Application - 1/19/2023 ri
415 N "STREET, SHELTON,WA 98584
MASON COUNTY L! JAN 1 9 2023 ELTON:360-427-9670, EXT.400
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. COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
BY ELMA:360-482-5269, EXT.400
'�;�� ' ' `��j' Buildm9 vhnnin9.Enwronmental 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 i Receipt Number)0).34E03112. Attach a plot plan and vicinity map.
�1\�13_/�(1(V1t 0 Cash 3. Submit this completed application with appropriate fee a minimum
lJ� wl.lJl� Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment I/19 I(a63. 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 -// / n� 7-le e__ 1pl,. 7 S4e-/-1c� Start Card# " 5-4/.S'4.
Drilling Firm / ir•%i�ft/SOr� Lr/c'-7/ .Qe. //,c Phone ;753-.cJ 7-73 3 Z
Applicant ie,//7 ( / / X, Agri,idsvr. /de-//.�.,//�%�y Phone Jiy ja6 7s3 If77
Mailing Address P•p . L1 <>yyz 7
City c, C r State 4)c , Zip y e-yy 5.2
Parcel Number 22./_72. -//- 9c 3O7
Directions to Site //' 3 f i 6o.r,.- /Uj /s z /-ino 77'e eve Al7 l�fo .>Pirre, Tiec,,,,7;
te,7T4i yl1w fa,-A- Si'' e,vJ.e/T•
Is the well site within 100 feet of salt/seawater? ❑Yes Ig'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 u e restrictions and additional fees may apply to all new wells drilled after January 19m, 2018 per ESSB 6091.
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Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only) ,„,(7 �Ov
Called In- 2-t 2- cv `0
YES NO TAG iF _ " �
❑ ❑ Driller on Site? P'
❑ ❑ 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? By
❑ ❑ 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? C_
❑ ❑ Do the well site set-backs appear to be appropriate? D
Comments --1O1--
—fie c�
❑ Pass ❑ Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site. Rcvised:2/7/2018
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