HomeMy WebLinkAboutWEC2019-00116 - WEC Application - 1/28/2019 '� "�'�% 415 N 6TH STREET, SHELTON,WA 98584
i.-41111111MASON COUNTY SHELTON: 360-427-9670, EXT.400
'11' i COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
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ELMA: 360-482-5269, EXT. 400
��y.- ' -'—n'/ Building,Planning,/ 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
Receipt Number T 2. Attach a plot plan and vicinity map.
(, 0 Cash 3. Submit this completed application with appropriate fee a minimum
0 Check of 24 hours in advance of initiating well construction. Refer to
J� rr Mason County Environmental Health fee schedule for cost.O U l3 Date of Payment /ICI 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 �3 8 t L3. I3 �d°ye r , Start Card# vJ E 3 2_ (c
, ((
Drilling Firm I'i�r c 6-41�a 0 r;1\; -t��-_. Phone 3{ Li.-Li7-63 3 c'S
Applicant 10c cd Ro� ec ke Q- Phone 3(,, 6 . 589- E4S-77
Mailing Address 543(2,f mo;. 3 y Cr-- Q 2
City S k c- I T c)n State Lei(A Zip q 8 53 Li
Parcel Number S20 ► -1- 2- 1 - c 000
Directions to Site Fir -C- Ric(4 ark 3,�ytr Pd1 -:2 r)c Dr i Vc-_6...i4.y d n ri l k+- ( e)
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? ❑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 tri n and additional fees may apply to all new wells drilled after January 19"',2018 per ESSB 6091.
Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only)
YES NO TAG# U Kra 1 ci 1 Called In 1 . - 1
❑ ❑ Driller on Site?
❑ ❑ 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 ',i r ri\15,''L-c--y
❑ Pass ❑ Fail Inspector Date Of (2_
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018