HomeMy WebLinkAboutWEC2021-00199 - WEC Application - 11/2/2021 6TH STREET,SHELTON,WA 98584
MASON COUNTY 415 N SHELTON:360-427 9670 EXT.400
‘17-17 COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
ELMA:360-482-5269, EXT.400
Bulking,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 NumberL/-59," 2. Attach a plot plan and vicinity map.
bCash 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.
Date of Payment t14-/Z/ 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 [f/o / '-et, oCk- 7 f h E Start Card# L,(!f L/l� 77
Drilling Firm Gccv,/,-<i E'— De—i.- / ) r`7�j Phone •
3b- c-3G— 9c�27'',S'
Applicant �jcv,e,,By rh0An 4 S / Phone •Z 6'1 cY/ / I /
Mailing Address i a/ 'E'er, 1-&f/ , f7 E7
City 6 ice/2,, e/iie i State `�m Zip 96"Sy.
Parcel Number ) / £ 3 L9 1(9 / Ioif It r-- (Qto
Directions to Site �
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 No 11
NOTICE:All proposed connec is to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
Water usage restrictions a a itional fees may apply to all new wells drilled after January 19r",2018 per ESSB 6091.
Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)
6#10W- b(91 C4-“, ii
YES NO TAG# Called In 14/24 ,af{ tl/'1 -f
Cl ❑ t{ f`Driller on Site? - L P t Al P12�P d
❑ ❑ 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? resnvisl
❑ ❑ Has the seal slumped? NOV2021
CI El 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? BY: ----
- .
li
❑ ❑ Do the well site set-backs appear to be appropriate? do 1�E Dian S i,�►'1A-< e
Comments j 'v 514 7,0\l_ ,)c 1 D�= l c-Apc .F h L-ce c` I_Oc,CE-.4. q A m
inspector l ti Date
i/ g12-i
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018