HomeMy WebLinkAboutWEC2023-00016 - WEC Application - 2/3/2023 "',,, 415 N 6T" STREET, SHELTON,WA 98584
�� MASON COUNTY v SHELTON: 360-427-9670, EXT.400
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COMMUNITY SERVICES, ( BELFAIR:360-275-4467, EXT.400
i 11 I r-ry 0 7fl93 ELMA:360 482 5269, EXT.400
ij::: \, �, Building,Planning,Ernironment iHealth,Community"ealth ' 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 aa— —7 5 2. Attach a plot plan and vicinity map.
)a�_ ❑ Cash 3. Submit this completed application with appropriate fee a minimum
oAJ CI(' Check of 24 hours in advance of initiating well construction. Refer to
C�/ � Mason County Environmental Health fee schedule for cost.
LJ�-'��� Date of Payment a .2 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART is APp F'Ilcanti aicei identification
Site Address at) �
� � (L`G Y1e.t�
CAee1e--Rot ' Si1e to Start Card # O 1 z `ra,
Drilling Firm kkpe_y-ke 3 SO'(\S Plum 04 1 Ylg Phone 3(4.1D "7y SOS
Applicant Ty(Q_VA A C c l,r, 1 nA Phone - �,p- L-t,q p- Lot ?)Q
Mailing Address t, 3 U` 1 km ((Lyle., 0 fo P )( V(
City 5\(1C' y1 State W fk Zip 9 PSG
Parcel Number a).\0 0 lo - ?\ —Ck C OC3
Directions to Site
Is the well site within 100 feet of salt/seawater? Elves KNo
If yes, a variance from DOE is required. Have you applied /received (circle one) a variance? EYes ❑No
NOTICE:All proposed co, ctions to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
Water a e restrctio sl/fd ditional fees may apply to all new wells drilled after January 191°, 2018 per ESSB 6091.
Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)
YES NO TAG # NI K 2_2_ Called In %' i (z ; i&-k \ i l 2-
3
❑ -i- Driller on Site?
a ❑ Is the well capped and Vented?
a ❑ Is there evidence of a surface seal?
❑ f ❑ Is there a 2" annular space on all sides of the casing? LA .1 , ZH b t.{2 SK
❑ 1:1- Has the seal slumped? i Z Z _ 9 cs Z t SS
Li .0" Is the well flowing or is there evidence of other leakage?
❑ Er Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long? N,-_ c'b"m Je:t
- ❑ Do the well site set-backs appear to be appropriate?
Comments ( (�S kk ?l
ass ❑ Fail Inspector ��f (ygrP
Z. ) Date 3(? I ( 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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