HomeMy WebLinkAboutWEC2021-00079 - WEC Application - 4/5/2021 -' :•rty..
415 N 6THSTREET, SHELTON,WA 98584
(110flo.;011"11i , MASON COUNTY SHELTON:360-427-9670, EXT.400
•,,tCOMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
;;; ,:/ Building,Planning,Envuaimental Health,Commun ay Health ELMA: 360-482-5269, EXT.400
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FAX: 360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information
I Instructions
1. Complete Part 1. Incomplete applications will be rejected
WEC� _ Receipt NumberCak j, 2. Attach a plot plan and vicinity map.
0 Cash 3. Submit this completed application with appropriate fee a minimum
Check of 24 hours in advance of initiating well construction. Refer to
i A Mason County Environmental Health fee schedule for cost.
LJIJOcrl ( Date of Payment ��. jai 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/ Parcejiclentification Tx)( Pctxc_24- 3
1 -�-�C��" /� ? o
Site Address abou l9, lu ivt; Gobori//C Aj 4 . Start Card # ���J2 D l Drilling Firm (�00s O`(aVRS- Phone —662 O aci v3 1.-7
5
Applicant `k ekk_ 2 o Phone Lp Li 63 (-3 5 O
Mailing Address 2.7 60' i Z 9 y A vt. SW
City c1,)o.A State O Zip l e67 0
Parcel Number 3221 Z ^-75 —DO55O
Directions to Site proPEX T J on_6 , k-i- cim it croiln.t :ico,t,(/1r1 t k� ��3`- 1 � 80 4
0 tVJ N-G N064, /iC7e 1
Is the well site within 100 feet of salt/seawater? ❑Yes ANo
If yes, a variance from DOE is required. Have you applied/ received (circle one)a variance? ❑Yes ❑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 and additional fees may apply to all new wells drilled after January 19'^, 2018 per ESSB 6091.
Applicant g�gnature
PART 2: Health Department Review (Staff Use Only)
YES NO TAG # Called In = -- 3+-t-(-iL
❑ ❑ Driller on Site? r o V c P okSEt' - R I& P
❑ E 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? RZCSgVX 1
❑ El the seal slumped? D
❑ ❑ Is the well flowing or is there evidence of other leakage? APR 0 5 2021
❑ ❑ Is there evidence of cascading water?
El Is there evidence that the seal is at least 18 feet long? BY:
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments ieNew StAtIrc DIETe KlsT (4 L b IN« ?E-2tACLt, Lee-)?(2-"Llltv(T (vat wre N) )7Z
❑ Pass ❑ Fail Inspector T_ S('E Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018