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HomeMy WebLinkAboutWEC2022-00028 - WEC Application - 2/24/2022 aiglar„ a D 415 N 6TH STREET, SHELTON,WA 98584 ,, 7•••,'� MASON COUNTY FED 1 y 2022 SHELTON: 360-427-9670, EXT.400 • COMMUNITY SERVIC BELFAIR: 360-275-4467, EXT.400 s1 ELMA: 360-482-5269, EXT.400 \n / Building,Planning,Environmental Health,Community health FAX: 360-427-7787 NOTICE OF INTENT TO CONSTRUCT A WELL Permit Number Payment Information l Instructions 1. Complete Part 1. Incomplete applications will be rejected WEC Receipt Number, -1 l`t1 2. Attach a plot plan and vicinity map. c.2,Oo ._ ❑ Cash 3. Submit this completed application with appropriate fee a minimum Check of 24 hours in advance of initiating well construction. Refer to Oa). Mason County Environmental Health fee schedule for cost. Date of Payment a! `� 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 /9d Aye-A( w Start Card # W t{O b�3 Drilling Firm 7 DRyt S t, A/i-i-mi G- Phone giev .-2?-534., Applicant ,U,iL) Ir�f r� 9)2 5. Y/ 05 Phone Mailing Address I 1iJ plijii‘p A' zkire-4. City 15 yii�121"j 7Z State 1"),- Zip `JC/ c�`� I Parcel Number 22 3 3 2_D_ L{() Qte, 30 Directions to Site get ,p j. e/ tot A , e ,ter /4,,, ii, Sj 1e OA Is the well site within 100 feet of salt/seawater? ❑Yes ('lo If yes, a variance from DOE is required. Have you applied'/`received (circle one) a variance? ❑Yes 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 ad .. nal fees may apply to all new wells drilled after January 19Th,2018 per ESSB 6091. 7 i Agent Signature PART 2: Health Department Review (Staff Use Only) YES NO TAG # Called In 3I S Fc� 3181LZ ❑ ❑ Driller on Site? 1 ❑ ❑ 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? ❑ ❑ Has the seal slumped? ❑ ❑ 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? ❑ ❑ Do the well site set-backs appear to be appropriate? Comments (4 iD T t IJ SP E-L t k IS ❑ Pass ❑ Fail Inspector Date This form may be scanned and available for public view on the Mason County Web site. Rcvised:2/7/2018 :' (loogIc x O Ili\Icn-t I\` x © Icii ak an la\. x ® mason('otott\ X ,CT E- C I gis.masoncountywa.go /mason/?find=2233224000 * • • Mason County WA GIS Mason County Homepage V 223322400070 X Q Parcel Number 223322400070 0 22 22400060 2 233 22 40001 0 223322400070 6 f, 61-14 y 1* =3 3200 60000 tiF } 223327500050 223320060010 2 233 22 40003 0 tiF 2233 2240003 0 Ak91�_ �4} gok • 'Citsap,Bureau of Land Management,Esri C... • ���