HomeMy WebLinkAboutWEC2021-00128 - WEC Application - 6/17/2021 till•Pr
,,�' �'"(+g\ 415 N 6T"STREET, SHELTON,WA 98584
5`, MASON COUNTY SHELTON:360-427-9670, EXT.400
0, i1' , COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
" ' r, ELMA:360-482-5269, EXT.400
Building,Planning,Environmental Health,Community Health
` j FAX: 360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
WEC Receipt Number
1 ^ 30/1 1. Complete Part 1. Incomplete applications will be rejected
2. Attach a plot plan and vicinity map.
acallolov ❑ Cash 3. Submit this completed application with appropriate fee a minimum
Check of 24 hours in advance of initiating well construction. Refer to
II
Mason County Environmental Health fee schedule for cost.
Date of Payment ij17Zf 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/Parcel'2"-( Identificationn /
Site Address -� i/ [� �t7 r Ul aY'C, ( ..dilliPr
Start Card # W EY Li S 0
Drilling FirmUCLak 1 g \Dr-, C L Phone 3nQO go/ Q(2cpz
Applicant D o.AA qPhone
t �(-••
Mailing Address ( (42 V+c&-i- , `Rd se-
city
% , �� State j/l, /q Zip 2360�y
Parcel Number 3%ac7- -G09(5
Directions to Site
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 restrictions an itional fees may apply to all new wells drilled after January 19'", 2018 per ESSB 6091.
_
Applicant/Agent Signature Z
JON ,PART 2: Health Department Review(Staff Use Only) tl� ' ��)
YES NO TAG # Called In 2 Z IL:2_ • ......
❑ ❑ Driller on Site? -roe 3 Re2--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 J\JL\t_ ,1-AL5P c;TZ�
❑ Pass ❑ Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018