HomeMy WebLinkAboutWEC2020-00165 - WEC Application - 10/5/20204'
ip;`' s4\ N 6TH STREET, SHELTON,WA 98584
,\ MASON COUNTY on Q 5 L" SHELTON. 360-427-9670, EXT.400
' „„ !� COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
- s, `0 ELMA: 360-482-5269, EXT.400
%r,,e .,. Building, Environmental Health,Community Health BY:----- =''o^`�'.-
r,.,,, N 1 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 Numberd0 " 2. Attach a plot plan and vicinity map.
`1O C) - ❑ Cash 3. Submit this completed application with appropriate fee a minimum
0� 0'�� ❑ Check i of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
00 lb 5 Date of Payment lIsIX) 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/ Parcel� Identification �V tt II [�
Site Address I L 702. E (O T �A U..Start Card# r' -/ /125
Drilling Firm rDo..kii 5 ' ' Phone &v chi 5 t. -
Applicant ' ,6.4 6/ �� Phone
Mailing Address 1:7O Ipx ‘---o
City U14-4 6V‘_ State (.,vyel Zip 6751911
Parcel Number Z2.,Z7_Q —?)I — C 1 1
Directions to Site
Is the well site within 100 feet of salt/seawater? ❑Yes,dNo
If yes, a variance from DOE is required. Have you applied / received (circle one) a variance? ❑Yes ❑No
NOTICE:Alf 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 19', 2018 per ESSB 6091.
Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)
YES NO TAG # Called In (o [• Z/ Fob
-� � toff, 2/ ‘.1)
❑ ❑ Driller on Site? San Mors
❑ ❑ Is the well capped and Vented? S
❑ ❑ Is there evidence of a surface seal?
❑ ❑ Is there a 2"annular space on all sides of the casing? y.
❑ Has the seal slumped? r___,
❑ ❑ Is the well flowing or is there evidence of other 100 age? G
❑ ❑ Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least'18 feet long?
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments j+,)S. I ) ev : fC:C
❑ Pass ❑ Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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Mason County WA GIS Web Map
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Tax Parcels (Zoom in to 1:30,000)
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