HomeMy WebLinkAboutWEC2023-00072 - WEC Application - 6/20/2023 N 6m STREET, SHEL ON,WA 98584
MASON COUNTY LII111S LIIJI' SHELTON:360-027-9670,EXT.400
COMMUNITY SERVICES JUN 2 0 9n93 BELFAIR:360-275-4467,EXT.400
ELMA: 360-482-5269, EXT.400
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FAX:380-427-7787
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.
❑ Cash 3. Submit this completed application with apt rtoyriate fee a minimum
ASV- ',U. Check of 24 hours in advance of initiating well constmcfion. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment a+3 4. Mason County Public must receive notifcatioa at least 24 hours
prior to the drilling of the well.
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PART 1: Applicant I Parcel Identification
Site Address S VV I A �O ( l p J. Start Card# �� p
Drilling Firm _ c11\ I1. Phone "SLO Y61 oFLZ
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Applicant Phone
Mailing Address SV7
City c y, State Nw zip
Parcel Number q) _ L 100 U , 0 r�
Directions to Site Ir.}o wr�P �AO�_ �QYLI�I( 1<d1 c lF�l —cove
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Is the well site within 100 feet of salt/seawater? []Yes VJNo
If yes, a variance from DOE is required. Have you applied/received (circle one) a variance? ❑Yes ❑Nn
NOTICE:All proposed canneciions to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
Waterusage restrictions co
and fees mmy)apply to all new wells drilled after January W,2018 per ESSB 6091.
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Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In
❑ Driller on Site?
❑ Is the well capped and Vented? �
❑ Is there evidence of a surface seal? Y
❑ ,,� Is there a 2"annular space on all sides of the casing?
❑ $#-I ❑ Has the seal slumped?
❑ .E!r Is the well flowing or is there evidence of other leakage? p I
❑ Z Is there evidence of cascading water?
❑ f2' Is there evidence that the seal is at least 18 feet long?
❑ ❑ Do the well site set-backs a{P�pear to be appropriate? >
Comments LDII�uf
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ElPass El Fail Inspector Date
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This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2019
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