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HomeMy WebLinkAboutWEC2021-00561 - WEC Application - 1/26/2021 1 ' � Y..I.L� ^ ZOZO 8 �::: JAN 2 J 415 N 6T'-'STREET, SHELTON,WA 98584 \'\ MASON COUNTY SHELTON:360-427-9670, EXT. 400 I` •t 1• BELFAIR:360-275-4467, EXT. 400 COMMUNITY SERVICES�Y._______. <1T� ELMA: 360-482-5269, EXT.400 :� ' building.Planning,Environmental Health,Community Health 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 -S Qj 2. Attach a plot plan and vicinity map. _ 0 Cash 3. Submit this completed application with appropriate fee a minimum Ne Check of 24 hours in advance of initiating well construction. Refer to GOc I _1 ^I,� f Mason County Environmental Health fee schedule for cost. �lL Date of Payment `OIIY,J�' 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 2253 E Johns Prarie Rd Start Card# WE42351 Drilling Firm Knapp Drilling Inc Phone 360-427-8174 Applicant Chavez Martinez Phone Mailing Address 2253 E Johns Prarie Rd City Shelton State WA Zip 98584 Parcel Number 32005-42-00030 Directions to Site Out Johns Prairie 2.1 miles on the east side 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? Dyes No 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 restric ions and addition fees may apply to all new wells drilled after January 190, 2018 per ESSB 6091. t ;1 Appl`: t/Agent ignature PART 2: Health Department Review(Staff Use Only) YES NO TAG# Called In K/ 1.1 Z - -i y I L ❑ Driller on Site? ❑ _Er- Is the well capped and Vented? )0' ❑ Is there evidence of a surface seal? 2- ❑ Is there a 2" annular space on all sides of the casing? ❑ ra-J Has the seal slumped? > , LA -2- O ' ct' Is the well flowing or is there evidence of other leakage? 1+1' 2 ❑ K" Is there evidence of cascading water? 23 - v 21 51 1 E Is there evidence that the seal is at least 18 feet long? eEr ❑ Do the well site set-backs appear to be appropriate? Comments V--r el f;z .ri t V 1 t na-) (IV rat;VI- . I,La tCaPn44 la ID awe ❑ Pass ❑ Fail Inspector Date ' This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018 Chavez Martinez Mason County WA GIS Web Map 1 <---- 3/p 1 _,... i _______ _..... _ l00�Pevd ,,y 0IZc`�ld r lif z al . il' 1 ii` P •Got t, * `,Section 7 T20N -R3W , ctc t�hs rn ------------- ----- Z x a l 1/20/2021, 1:16:10 PM 1:3,070 0 0.03 0.05 0.1 mi E3 County Boundary 1 ' I ill ' + 0 0.04 0.08 0.16 km Tax Parcels (Zoom in to 1:30,000) Sections Sources:Esn.HERE,Garcon,Intertnap,increment P Corp.GEBCO,USGS. FAO, NPS, NRCAN, GeoBase. IGN, Kadaster NL, Ordnance Survey, Esn Townships Japan.MET",Esn China(Hong Kong).(c)OpenStreetMap contributors.and the GIS User Community Mason County WA GIS Web Map Application Esn,HERE.Garmin.FAO.USGS,NGA,EPA.NPS I Richard Diaz I k , q f V 330 t `9`Q't t cp .ZS rap—-t$ too—. /4 Z cS1Mkl4c. , 0 --t8"-1' YJ2,...ic V2.4AA. A . L.S 4- G- w 11ZAots, No 0\be.yk• •CnaveL CALIAlotet- 9s... .. ric :v-�. 1 Saw-e• • 5k)pJ-A-e-Q • 3,-DOS -k--o30 tA...v.. Cobb s a\q t .)0V1145 7.-a-1 r:c- ELa 1 ( 61,w,li •1•t R4$S'{ OCleanout 02 1,200 Gallon Septic Tank 2 -O0' - A'PP'`�X- • 2-Compartment with Effluent Filter it. w z,Ka„j, 0 D-Box with speed-levelers and cover to surface 0 14), 1 c). ; : Si 3., g9: �.p 1„� b� Xtpd rrww,y A •AA�, t0' XbD' Reser44 4N16f-4PAULLA51J4OHNSON0•F. Bed 41 © A r - - — "1 `- - -Jg 1:1:qkdSiONtk.. • ExxpiRES I t'f. 5 tore O.E • 0 . _ , , P Pro f o6.e.4 Ic'O ',e/,� 3 R V Qy 14-o e sl Al 7 40 , I;;S C.ve40k 1 0 c.a.+101,‘ 1—tPr"Cif ED NOV 0 6 2020 MASON COUNTYFNUIRONNIENTAL HEALTH 1 Printeerom Mason County DMS NYC Printed from Mason County DMS