HomeMy WebLinkAboutWEC2023-00029 - WEC Application - 3/23/2023 3w,...rr 'ti 415 N 6TH STREET,SHELTON,WA 98584
` MASON COUNTY SHELTON:360-427.9670, EXT.400
J COMMUNITY SERVICES ( BELFAIR:360-275-4437, EXT.400
. /' 1 ELMA:360-482-5269, EXT.400
41 j Bwldiny,Plannny,Environmental Health,Community I leelth V FAX: 360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number ; Payment Information Instructions
1 ,t^�� .�j l/n J 1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number(Y `I'1` 2. Attach a plot plan and vicinity map.
2 )--Qfl'7 CI Cash 3. Submit this completed application with appropriate fee a minimum
1/ lJl lJ Check of 24 hours in advance of initiating well construction. "refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment 23 ']"� 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 t \/� \�9 1'G& V,- `L/ Start Card # w c2 1 B
Drilling Firm v i 5 ( t
/ I\. l�( Phone 3(OO )I— ( (n1Q Z
/ V —2.—_
Applicant Applicant i C,� n O 1(3S( Phone
Mailing Address ✓" t O /v E 'AU( S �/l1'1
City ?ac-tA\ • State \NPr Zip / U
Parcel Number '12t\ L1 II I 00000
Directions to Site at k.,e eKfi
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 [ jNo
NOTICE:All proposed connections to new wells are subject to water adequacy requirements at time of building permit per Mason Ccunty Title 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled after January 19'", 2018 per ESSB 6091.
Applicant/A nt Signature
PART 2: Health Department Review (Staff Use Only) it
YES NO TAG # Called In
gTZ3 Fviz s19! z3
❑ ❑ 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? 5 1i]t VI 14
T
❑ ❑ Has the seal slumped?
❑ ❑ Is the well flowing or is there evidence of other leakage? O-t MAR 13 2D23 I_.
❑ ❑ Is there evidence of cascading water? en
❑ ❑ Is there evidence that the seal is at least 18 feet long? BY: (,
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments N`
❑ Pass ❑ Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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