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HomeMy WebLinkAboutWEC2023-00085 - WEC Application - 7/24/2023 0 MASON COUNTY ./-k ) 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670, EXT.400 COMMUNITY SERVICES (_Z BELFAIR:360-275-4467, EXT.400 jit'./ �" ELMA:360-482-5269, EXT.400 euNdng Planning,Environmental Health,Community HealthFAX:360-427-7787 NOTICE OF INTENT TO CONSTRUCT A WELL Permit Number Payment Information Instructions 2.&7.3 - 1. Complete Part 1. Incomplete applications will be rejected WEC Receipt Number a3's Z L. 2. Attach a plot plan and vicinity map. ZD 23-cue a$$` El Cash 3. Submit this completed application with appropriate fee a minimum Check 13 c•t of 24 hours in advance of initiating well construction. Refer to Mason County Environmental Health fee schedule for cost. Date of Payment 1 ��'�I Z3 4. Mason County Public must receive notification at least 24 hours prior to the d . . S 7 TC PART 1: Applicant!Parcel Identification JUL 2 4 2n21 Site Address 716 E Thornton i Rd Shelton WA Start Card# WE53496 Drilling Firm Advanced Drilling BY; - +Phone 360 273-7735 Applicant Michael and Tanya Hatfield Schaefer Phone 360 292-2985 Mailing Address 760 E Thornton Rd City Shelton State WA Zip 98584 Parcel Number 22135-75-90144 Directions to Site Pickering Rd to E Thornton Rd, end of road, last lot 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 ❑Nlo NOTICE proposed con tions to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68. Water sa restric ons additional fees may ap•y all new wells drilled after January 19'.2018 per ESSB 6091. Applica /Agent Signature 7 PART 2: Health Department Review(Staff Use Only) YES NO TAG# -6T NJ O Z Called In V2112,3 c& WJ 2i J23 CIDriller on Site? .1.a' ❑ Is the well capped and Vented? „ r- ' ❑ Is there evidence of a surface seal? i{7. - SS 3 11110 4 ,T ❑ Is there a 2"annular space on all sides of the casing? — ` LZ. FS li So C. ❑ , ' ❑ Has the seal slumped? ).1 o'r x0Se 4"/CD ❑ 2-- Is the well flowing or is there evidence of other leakage? ❑ 2 Is there evidence of cascading water? ❑ ❑ Is there evidence that the seal is at least 18 feet long? 4 T t>,YS VC7 g" ❑ Do the well site set-backs appear to be appropriate? Comments -Pass ❑ Fail Inspector Date I/4Z3 This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018 ,r/i8i23','9:41 AM layout.jpg -3 vv bI1j https:Iimail.google.com/mai/u/0/#inbox?projector-1 1/1