HomeMy WebLinkAboutWEC2023-00093 - WEC Application - 8/7/2023 O415 N 6T"STREET,SHELTON,WA 98584
lai MASON COUNTY I1 Ir, O 7 ar�� SHELTON: 360-427 9670,EXT.400
COMMUNITY SERVIC AUG BELFAIR:360-275-4467, EXT.400
ELMA:360-482-5269, EXT.400
' ur,�'i &Jading,PlanningEnvronmentalHealthCommunityHealth FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number payment Information Instructions
tc 1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number •• ,.7 2• Attach a plot plan and vicinity map.
d 3 — Cl Cash 3. Submit this completed application with appropriate fee a minimum
4:96
Check of 24 hours in advance of initiating well construction. Refer to
t-�
C �'('x�� +� Mason County Environmental Health fee schedule for cost.
Date of Payment 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant 1 Parcel Identification ��� �'
Site Address I ZJ I /�aare �l / S/V(1�,140 - Start Card# w 6
Drilling Firm T J r D rf I <1 Phone d—OO/-4 /
Applicant ClartlID tnl 4 Y Phone 540 —I/L(0—9 909
Mailing Address ( (-?j ( E al-CO r l.--N //
City �Lt1 �V State �k Zip ct (} S-a Ll
Parcel Number '2 U ICI rr 2- 2 — 003 O
Directions to Site ri. �, Qt1 Prc�TOjr Ak-e. YAM 0a /--- +0 Si o in p-E--k •
Is the well site within 100 feet of salt/seawater? ❑Yes Oslo
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.
7- (- 1r-)
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# -pb ly 8 Called In 41S Foil 4 tS Cz3
❑ ,2--- Driller on Site?
Zr ❑ Is the well capped and Vented? /1 z + `LJ
ElIs there evidence of a surface seal? �i
❑ Is there a 2"annular space on all sides of the casing? — ( 2 Z. 5?9 J S'2 q1
❑ ❑,k Has the seal slumped? l`i` `'$' Ja g
❑ Is the well flowing or is there evidence of other leakage?
❑ , Is there evidence of cascading water?
❑ ❑4it Is there evidence that the seal is at least 18 feet long? t bT OI3a 'D
❑ Do the well site set-backs/ appear to be appropriate? LL�ndad- a
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Comments no Loieot ? his ifxif' COaI.4 tttiT,,,di 'aoro 1 rh fd0
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0 Pass ❑ Fail Inspector "" l Date 9 i i I �3
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�� This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018 \
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Mason County WA GIS Web Map
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El Tax Parcels (Zoom in to 1:30,000)
i1/4\1 1 5 )9.1 (,�1 Mason County WA GIS Web Map Application
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