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HomeMy WebLinkAboutWEC2021-00159 - WEC Application - 8/30/2021 , , 415 N 6T"STREET,SHELTON,WA 98584 ir. MASON COUNTY AUGl� 3 0 2021 SHELTON:360-427-9670, EXT.400 COMMUNITY SERVICES'' BELFAIR:360-275-4467, EXT.400 tee, ELMA:360-482-5269, EXT.400 ' \ i/ Budding•Plammn ,EnvironmentalHealth, Health __, FAX: 360-427-7787 9 Community BY=- NOTICE OF INTENT TO CONSTRUCT A WELL Permit Number Payment Information Instructions -• 1. Complete Part 1. Incomplete applications will be rejected WEC Receipt Number b 2. Attach a plot plan and vicinity map. av�1oC 1 _ ❑ Cash 3. Submit this completed application with appropriate fee a minimum ❑ Check of 24 hours in advance of initiating well construction. Refer to Mason County Environmental Health fee schedule for cost. SO I. 59 Date of Payment 8(34)(2( 4. Mason County Public must receive notification at least 24 hours prior to the drilling of the well. PART 1: Applicant/ Parcel Identification 1 \ Site Address Sc110 S� --T(�cL fog Start Card# lb tA5(o5J Drilling Firm 4rcj1/416- (;\Vokc a-,n.c- . Phone 33(0o- y 2-33q,c J Applicant )CUB-co.v. SvA1a& Phone 3(ot,_S as_9Ft: lo Mailing Address "To oxc 1Zct 0 City Skl�1,�Ov, State W o_ Zip 9 s1t Parcel Number ZZo 31 S 1 00022-- Directions to Site Ng•ce.SS 1Mn-1 exjs r GU'' A-v • Is the well site within 100 feet of salt/seawater? ❑Yes . No If yes, a variance from DOE is required. Have you applied/ received (circle one) a variance? ❑Yes SNo 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 usa e restrictions and additional fees may apply to all new wells drilled after January 19`^, 2018 per ESSB 6091. 7------ iast,.C&__c-,rc_ ►4_77,n\t_ Applicant/Agent Signature PART 2: Health Department Review (Staff Use Only) YES NO TAG# Called In ? `f- 5 h. '-Z.Z all ❑ Driller on Site? ❑ Er Is the well capped and Vented? ❑ Is there evidence of a surface seal? e ❑ Is there a 2" annular space on all sides of the casing? ❑ ❑ Has the seal slumped? i,i O Q ❑ ❑ Is the well flowing or is there evidence of other leakage? i\; n v ❑ ❑ f Is there evidence of cascading water? N o, 0 ❑ ' ❑ Is there evidence that the seal is at least 18 feet long? (12( s❑ Do the well site set-backs appear to be appropriate? i p `/ Comments ? 17/. kl 1�z . ` y 70 .z fz fic , ( �c z � 1 l ❑ Pass ❑ Fail Inspector •(/ Date 5I S 27— This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018