HomeMy WebLinkAboutWEC2023-00067 - WEC Application - 6/2/2023 ' %, t 11 v
1 jUN 0 5 2023 `' 15 N 6TH STREET,SHELTON,WA 98584
MASON COUNTY �, : 360-4277-9670, EXT.
lk ;: COMMUNITY SERVICE '3� BELFAIR:SHELTON 360 275 467,EXT.400 400
ELMA:360-482-5269, EXT.400
Bu,Iding.Planning Environmental Health,Community Health Ov 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 3-.4 A) 2• Attach a plot plan and vicinity map.
.�f�,a - 0 Cash 3. Submit this completed application with appropriate fee a minimum
o(w —Check of 24 hours in advance of initiating well construction. Refer to
CPO
�1 /S/a23 Mason County Environmental Health fee schedule for cost.
l Date of Payment BL 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant I Parcel Identification 11 y_—5 7� I ( ,`/�,
Site Address �"T O -E k-t or I 4yt.t.i I Start Card# V ' 0
DrillingFirm
\ )i Dirt i kI Phone 360 o 'i, 75—
�R 1
Applicant , 5 c 'sc;fi'S JL--e-/ Phone ! -boo 633 I
Mailing Address �7 F 611€0,1V-V"!4n-
City S kp_qv& J�State O Zip py 1 €i 6 "-/
Parcel Number \/LA T 1lc:0 0.0 I 0 /�� f r
Directions to Site �Kti'i.4 7k f e LA' 4 £� GI\ or � O -
Is the well site within 100 feet of salt/seawater? ['Yes ❑No
I s I otr4 SI,ieleS � .
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 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# Called In '1L ZO 17-- Fail l 2 123
❑ Driller on Site?
j Is the well capped and Vented? Cir l LP. flt. "3 4 Sc
TJ ❑ Is there evidence of a surface seal? "�2- . �f S� ( J
j I ❑ Is there a 2"annular space on all sides of the casing?
❑ la Has the seal slumped?
❑ 0 Is the well flowing or is there evidence of other leakage? M
❑ tgi Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long?n y-1 ob v'v.cs,(
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments Cap rtl?.eGl�-10 Y)c Clr(`tNa4r QA1-5-S d ,-- A
t Pass ElFail Inspector s SitA,l(1✓ RAI) Date old 03 NAZI
This form may be scanned and available forpublic view on the Mason County Web site. Revised:2/7/2018
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MASON COUNTY ENVIRONMENTAL HEALTH•
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