HomeMy WebLinkAboutWEC2022-00144 - WEC Application - 9/20/2022 \ MASON COUNTY 415 N 6rii STREET, SHELTON, WA 98584
r SHELTON: 36)-427-9670, EXT. 400
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1 'I�' 'TsI COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
iit..„...,„....----i / ELMA: 360-432-5269, EXT. 400
`,`r5 Building,Planning,Environmental Health,Community Health
\.,.:-,nrs t,;^, F Ah: 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 Number�1 'y ) 2. Attach a plot plan and vicinity map.
2022-00Vyu 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.
Date of Payment U It I
TT 4. Mason County Public must receive notificatioli ai least 24 hours
prior to the drilling of the well.
PART 1: Applicant/ Parcel Identification Site Address I ZiL03 1 Ti 5 ) 0 CL1 13e 1 t r Start Card# W r `�rn
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Drilling Firm Do\\ 1S J r I M \ t ►'te.j q� Phone
Applicant ' V\ t \-.. Ta I 1 kg.)-e 1'1 lr`L Phone
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Mailing Address i-/ 7 O'/- -1 9111 fk'J-Q C-+ / V VUlr
City C-1 I9 )--1-0✓bor State w�G/ Zip
Parcel Number '2 2 '7_2,-, 0 - 5 / - t 7 (- '
Directions to Site UV S— be f o r-e. 7 Wa i1 cat 51- pctr/L onl Lef-4- ,
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 E•Nc
NOTICE:All proposed connections to new wells are subject to water adequacy requirements at time of building pormit per Mason County Title 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled after January 19t'', 2018 per ESSB 6091.
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Applicant/Agent Signature c==== •
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PART 2: Health Department Review (Staff Use Only) MI
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YES NO TAG # ��Q / J Called In �ZR/77G� .o
❑ 4 Driller on Site? /y
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❑ Is the well cappl and Vented? # w
❑ ❑ Is there evidence of a surface seal? )*fe.s il Gr7'(6 ev N.P4r ha i
LI ❑ Is there a 2" annular space on all sides of the casing? cm CD
❑ Has the seal slumped?
E LI Is the well flowing or is there evidence of other leakage? 4j4'GY- r'► rP ich/M_
❑ P Is there evidence of cascading water? 6"r ho-
❑ ❑ Is there evidence that the seal is at least 18 feet long?
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments _
❑ Pass ❑ Fail Inspector Date 6/g/2C 2—)
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
Mason County WA GIS Maso' c.our.t
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C--'--"`� ~ -'"`T 12coci St 1 (JCS
---�' Parcel Number: 2222)3400090
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Parcel Number: 222203400090
Legal Descriptir,n:
\ TR 9 OF GOVT LOT 3
Size in Acres: 2.35
`' View Scanned Property Records
Check if permit:ar,,available
'j• Information may be outdated, pleas
Taxsifter for up..o Gate information.
Owner:
ee° TOLLKUEHN, P.^.ICHAEL H &JULIA E
4704 79TH AVE NW
GIG HARBOR WA 983356107
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I Range: 2W
I Township: 22N
Section:20
Zoom to
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300ft
122.964 47.376 Deigrei
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