HomeMy WebLinkAboutWEC2021-00162 - WEC Application - 8/30/2021 /• t AUG 3 C 1
MASON COUNTY 202 415 N 6TH STREET, SHELTON,WA 98584
%" SHELTON:360-427-9670, EXT.400
1 . ) COMMUNITY SERVICES. .�__— BELFAIR: 360-275-4467, EXT.400
`, / Buildinq.Planning.Environmental Health.Community Health -"—" ELMA:360-482-5269, EXT.400
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 Number 2. Attach a plot plan and vicinity map. •
aDOZ I ❑ Cash 3. Submit this completed application with appropriate fee a minimum
! 0 Check of 24 hours in advance of initiating well construction. Refer to
CC�f, _ Mason County Environmental Health fee schedule for cost.
) tWG Date of Payment 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
I
PART 1: Applicant/ Parcel Identification
Site Address ZUt E 1e,5e,-. LCA\<A_ GI Start Card# WE 4S55Z
Drilling Firm ' coca. -Di i\\lI\A-S :L Phone "l1k,0-g2.14-33RS--
Applicant P&v1 C_0r' .% Phone q3(.Q- (p63- 31-10\
Mailing Address ?p 1 eic f a0
City Cj ke...lko,\ State Wc` Zip I�S �ZI
Parcel Number 3 ZOO 3 - I l - g00Z3
Directions to Site "frow. } 3 41)r11 o,-- rnASe .. La.L v-cQ look.. cor 5;1rt.. ot,\ le..+1-
Is the well site within 100 feet of salt/seawater? ['Yes ONo
If yes, a variance from DOE is required. Have you applied/received (circle one) a variance? ❑Yes ctEtNo
NOTICE:All posed connections to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
Water usage strictions a itional fees may apply to all new wells drilled after January 19th, 2018 per ESSB 6091.
Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)
YES NO TAG# it \ . 3 Called In 31 Zc E>rIZ IA/72
_ErP" Driller on Site? r
❑ Is the well capped and Vented? q 7 �; 7 G
❑ Is there evidence of a surface seal? G Jli 7 S
.� Ill Is there a 2" annular space on all sides of the casing? / 2 3
❑ Has the seal slumped?
❑ Is the well flowing or is there evidence of other leakage?
❑ gr Is there evidence of cascading water? J; L n Su��'�
❑ El Is there evidence that the seal is at least 18 feet long?
❑ Do the well site set-backs appear to be appr priate?
Comments ()tivt(tiallV) 0)211 (Jiffs-f- �/,tiSh,,f, r lZ�' `5` r
j l Pass E Fail Inspector1 11 )11; 1,✓ .1 Date 3/ic1/Z 7i
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018