HomeMy WebLinkAboutWEC2021-00172 - WEC Application - 9/7/2021 6TH STREET,
,WA
584
MASON COUNTY �v, 415 N SHELTON: 360 427T 6N0 EXT8400
firoi t COMMUNITY SERVICES 4� BELFAIR:360-275-4467, EXT.400
ELMA:
SEP 0 7 2021 360-482-5269, EXT.400
Building.Planning.Environmental Health.Community Health FAX: 360-427-7787
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 a1.664,5 2. Attach a plot plan and vicinity map.
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„ ❑ CashN1St 3. Submit this completed application with appropriate fee a minimum
- Check of 24 hours in advance of initiating well construction. Refer to
cc) na Mason County Environmental Health fee schedule for cost.
9
Date of Payment ll 101 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/ Parcel Identification nn �
Site Address Cj 3A0 N e )Jo( s\�wr� t�->'i\ Start Card # UJ E- y S`I1 L
Drilling Firm A-('cc,A;t.. --0r7\.„5 "Imac... Phone 3(.0- `12-6'339.
Applicant 3 re,c).,o• \0•.\(-5 Phone ZS 3- Z(1 2- ?::)Ota
Mailing Address Pt $of nct0
City S\"11 ,kt . State \-ca._ Zip G'�� "
Parcel Number 22 Z t oS 100 `\OU
Directions to Site c ,.a.rtSS vim+-h-441. air . ...
Is the well site within 100 feet of salt/seawater? ❑Yes ENo
If yes, a variance from DOE is required. Have you applied/ received (circle one) a variance? ❑Yes Olo
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 may apply to all new wells drilled after January 19th,2018 per ESSB 6091.
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Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only) (c,.a-,_cetic.I. 2x 10'4``')
YES NO TAG # Called In S 4- - e-t>- 41- (i-2-----
CI ❑ Driller on Site? Y`z
CI Is the well capped and Vented? 3�
❑ ❑ Is there evidence of a surface seal?
❑ ❑ Is there a 2" annular space on all sides of the casing? Z_
❑ ❑ Has the seal slumped? C�
CI �1
s-
❑ ❑ Is there evidence of cascading water? ail
❑ ❑ Is there evidence that the seal is at least 18 feet long? �O
CI Do the well site set-backs appear to be appropriate? —
Comments - NOT i ni S CE-c i t b ->
CIPass ❑ Fail Inspector Date r-
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018