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HomeMy WebLinkAboutWEC2022-00144 - WEC Application - 9/20/2022 (2) f~`' , 415 N 6TH STREET, SHELTON,WA 98584 '-. MASON COUNTY SHELTON: 36)-427-9670, EXT. 400 l"' COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT. 400 ELMA: 360-432-5269, EXT. 400 Building,Planning,Environmental Health,Community Health F AX: 360 427 7787 NOTICE OF INTENT TO CONSTRUCT A WELL Permit Number Payment Information Instructions ��rr�� 1. Complete Part 1. Incomplete applications will be rejected WEC Receipt Number 20)2 (351 2. Attach a plot plan and vicinity map. L. 2c•�2�"V `lJ'.Oty11 Cash 3. Submit this completed application with appropriate fee a minimum Check of 24 hours in advance of initiating well construction. Refer to Date of Payment ^ Mason County Environmental Health fee schedule for cost. �/� 4. Mason County Public must receive notification at least 24 hours prior to the drilling of the well. PART 1: Applicant/ Parcel Identification " wso58 Site Address 1 .,? 1 T15 t� 1 0 +(,g ' e.WCA i r Start Card# Drilling Firm Jo " 1S )r i 1 \ t yttfq. Phone Applicant OR t \(----t- i 9 i 1 w,.)J -e-h it i Phone Mailing Address . -/ 7 0'/- "31 th /kJ-e C I- Al .i City CIO 1--1--0 vbor State VW----- Zip 9 j 3 T l C ,.z Parcel Number '2_2. ' �/_ e.) - ' 1 O ' .3~jI "-- J --- Directions to Site JU 3- be_f-or-e TNot h dil 5'fr, , ,?c r / Oil Le-f - 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 ❑:Nc 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 19rh, 2018 per ESSB 6091. Applicant/Agent Signature © . I r PART 2: Health Department Review (Staff Use Only) N YES NO TAG # 5P61. 1 Sy Called In c jz 4 va 1 ❑ Driller on Site? /yt( 'y MI i ❑ ] Is the well capped and Vented? w i ,$ El El Is there evidence of a surface seal? f*IS1 GCIC'(( ev r hp'Grd •, ❑ ❑ Is there a 2" annular space on all sides of the casing? o ` CO ['IQ ❑ Has the seal slumped? Cci ❑ Is the well flowing or is there evidence of other leakage? 1,\ 4/ r 1 rvyy), 1 ir M. ❑ Is there evidence of cascading water? 6v31,141 ha ❑ ❑ Is there evidence that the seal is at least 18 feet long? ❑ ❑ Do the well site set-backs appear to be appropriate? Comments ElPass ❑ Fail Inspector Dat /2 i 43 e This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018 9/14/22,8:49 AM Mason County WA GIS 1 ' Mason County WA GIS -F Nir 222203400090 X Q — Show search results for 22220... Ni ri '.L4..,---- . '. ----t.oa, ..----------T . ..... , _,&.,_ _ .... , ,. .),....,„:>_,___ 1 , . ,,„,-, .e.5Q...,00 . __ . . ._.._ _....._..... J Parcel Number:222233400090 l Parcel Number: 222203400090 Legal Description: \ TR 9 OF GOVT LOT 3 Size in Acres: 2.35 View Scanned Property Records Check if permit:aro available Information may be outdated, pleas Taxsifter for up,o Gate information. Owner: ri,�"' h TOLLKUEHN, .^.ICHAEL H &JULIA E 4704 79TH AVE NW GIG HARBOR WA 983356107 Range: 2W Township: 22N Section:20 Zoom to 1 — 391ft '\Ab\\ Q \1\al—bl vcv. 300ft -122.964 47,376 Degrees https://gis.masoncountywa.goV/mason/?find=2222034000908,_g1=1'zu15e7'_ga'MTM5NDA4MzY5MC4xNjU4MDgyNzk2'_ga_81P1QX4XM i'MTY2M... 1/1 ____ /UL WED Uti:5l FAA Z754U'LL Yhri'K1J 12(40 f-{ I¢JUU. -lam l (A..}-€ S tt 6S Ceti S u i GN. 7' S 1-- ©�_ r," reA,i> " 1L-V hide Id"el jet It id ilium W0013A 42 3e0IS A >Ol 11+M"icailddr 10U L2S 7s1Q1Uill •S:L ' " 1 @�11]A WNW) `�` d]LVA N3d0 a1IN1if1M ' `` I \ \ .. ,.. —. ..1*- .i-16it: 1 I JA]Av7 ]Sl / Mt/+710e n ' M]iSAS 311d3S''111SCO3✓ 171i AI T3<3 31VMl�bddr \_._...„_.________. — 1 NAY i I V-- aWL 3913 I-.- --\ ( MIAs J0 7r13i 311g3 I aw+l Jn Mel-7 .. 1 . Jam_ Hasa 1•17310+S 01 wort A 3']07 31r14Ex0ide'• I I 7dlVW J U131VA 640IH 17lr 4 3 3iWL 3 ddr 1 A1113cIea 13TVIS I --3 i,. t .ram ram„,-.)' 'h fir..,.._ %,e..4-k `--N i • r '� 1 , I� 1-P.4..i .+i' i,..t J•''kr/t .�1:"s1L�i(1iiik: F•et.,i.: :•yp.. l'sc.i r, .. re...: .lee. - e s.: _ C!l , .-l..:a o-A.o ikti..i i g-:�.e. ra.l. r•.ta.:l`Pt.l' MASON COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT NO. bWG — >y�u _ to 426W. CEDAR/P.O. BOX 1666/SHELTON, WA 98584 Date Receipt N lg� 3 I, PHONE (360J"427-96 y0 Amount$ MI �b . '`Ye l CARP E- z PROP OWNER:T DATE: 7. CHECK APPLICABLE I ;M' goo1 4r ��SID 1 5. MAILIN ADORE 8: DAYTIME P OO NEW SYSTEMNE: eg. _�_ x�o \\\et 26>7 275— 40 tp REPAIR SYSTEM _ ++ MAINTENANCE REVIEW SINGLE FAMILY �_ m CITY: S �TE. t� at,_ q ZIP: I PROPEF3]Y ADDRESS: ulttkR z t 1 a.? 1 t\w , i n 6__ -42..2 1-+`r' _ SPECIFY: SPECIFIC DIRECTIONS FOR LOCATING SITE: PRIVATE WELL COMMUNITY WELUPUBLIC SYS 1 M L''� trn.r.► i�el ' . ,r- }�• aF, -[.tia�✓�s----` ^Kn SYSTEM WF1 N IN S�fa•,e� t_ t: 4e o �--(1* /6,4.S pStpLQ es1.d' SYSTEM NAME Iw11_APPLICANT . . . - •• - , ' NAME AGE i... . O IN Name of ��) Lot i nr, ft.x ft. MAILING, �,S5, ,._ i pp f Installer �I4t�San Covt 57. v . i Size: 0 0 •' +«etr TELEPHONE , • 27 - 4 10 Name of Number of /SIG dkRE . I- Designer of Bedrooms ? X i•. :1:.. A IS ),-M PLOT PLAN t--1—� I .�d\ fir" I I- Dr w-adlq'Ienalonal plot plan. �� In r t CO i IO p - e-•Ja location oft fwbh�aet j r earl fICeslio " iI 5, f I'-.. p r ,' y I tdi Avays her r�Q$, 4— r"t ✓t e l l5 P.sto v`t fi I`' f D�l zzzZo -3 /� t7ac,I c? 10 r Li QT IN }I- S EM IGN CV /201130" fc.- n 1 -� I xGFFICIAL USE ONLY. DO NOT WRITE BELOW DOUBLE LINE. T� 1 SOIL LOGS 74-‘ 3 -ru-t$z C7-ao e_oc..e,�7 5as44 b-S- Cos way 5- - }e o- q o co.,�y 5 -..•1I w/ M� y rct Jr!LS ` t -6 " i....v on`33 �� ,,A 5.5 h f/y zo-S S 5 l` � ez.,«c � ri / n00-15 � ' Loa .44 y 5a.^t LOu.Ky �✓t� lV tKff� '. 5G* Co1.w,p;! 4ro/'S3..w1 So,l F -A+ warr i I 1 DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIRE,M ;NTS [Finding ) I Score Designer Level: ❑One ¢(Two Sell Type a e- f SoiSeptic Tank Daily / Depth /In. 1 Capacity: 'Zo^ Gal- Flow: p I GPD Slope `� Yt 0 Doew, -TH Appl. ?Y Inett. Parcel Size [- ) Aa Rate c, GPD/FTs Area 4-50 F 2 Distance to Shoreline <AOo rt I Total IS. Inspector Date i 6-- Ge.„.. SOr1 Q '4 119i COMMENTS/CONDIAIONS FOR APPROVAL crt A e. t r e" y�t`a -C• /� t f �,) /.(4-.t. Cr - l.J`itt_ sic Vd1AtcL4 10, tt- .11, 4ci k t0(wT^1( i� HOvY-� i-L/4, (1 )trf-tt� un0•er 1iJ'.0 . - AY O';$s r, �19$ Ft�V'+V1 C• IM h, T (� �/r,.;-1 t x•4 fie +1.t.. veto, :or. d.,L. o-4 it ,o..e. A.ci.r t./...V1 all+r' ! ` ?J„is• •All on-sfle sewage systems must be designed by a Mason County Certified Designer or a Professional Engineer. •All on-see sewage systems must be installed by a Mason County Certified Installer,unless prior approval le granted for a homeowner i' st(ilatlxi of a gravity system in such cases a preliminary on-stte meeting between health department staff and the homeowner is required. •On•slte sewage system design approval does not Imply other building site requirements(i.e.RLC.Water Adequacy)have been met. •Any change from the specified use of the property or any site alteration electing the system design may invalidate this permit. •This permit expires 2 years from the date of site review.Denial of this permit may be appealed to the Health Officer within 10 days of denial date. SITE REVIEW: DESIGN REVIEW: Approved 0 Not Approved Not ApBY: G. DATE:a . f)i7 BY: GDATE:Atta.s/7 1INSTAATlON: ploVad BY:e(kyxe.1NAc , .j, sk DATE: f"1'� -,1F k° t"' .rihh'tl.�der„°'k+fe ifs t �o"`<er6. iifa s�"' fk lei y Oner s Copy BOTTOM:Aeolicant's Coo