HomeMy WebLinkAboutWEC2023-00053 - WEC Application - 5/22/2023 o IIIvIn
4' N 6TH STREET, SHELTON,WA 98584
\ MASON COUNTY i MAY 2 2 2023 L SHELTON: 360-427.96 '0, EXT.400
��' Fj COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT.400
W
8uildiny,Planning,6rvironmentnlHealth,Community H BY: ELMA: 360 482 5239, EXT.400
lea' 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 4 2. Attach a plot plan and vicinity map.
.),__M 0 Cash 3. Submit this completed application with appropriate`ee a minimum
)49 Check of 24 hours in advance of initiating well constructior. Refer to
Mason County Environmental Health fee sched•ile ror cost.
Date of Payment 5/2 2,/23 1 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/ Parcel Identification _ —7 ( ��C
Site Address
" 16 9D �1 e_i- lop Start Card# Ni::: - L.(:)-
.
Drilling Firm .c)O^v, -,17)I'i ) I t la l Phone 7(FC'•-tf)J -`7 > 7
Applicant Phone
Mailing Address 1 -2_ r �C n I°� )1 C ,^ v�City S �)
IY�c .�
late \,t`J f I j_ Zip 63`rr) �j/l
Parcel Number 3 -\ U \ "2-oo0 3 U --
Directions to Site U i.A V(-jk.%in - (,(?_ C '1 Le -)-
Is the well site within 100 feet of salt/seawater? Eyes 4No
If yes, a variance from DOE is required. Have you applied I received (circle one) a variance? Oyes ENO
NOTICE:All proposed connections to new wells are subject to water adequacy requirements at time of building permit per Mason County Titre 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled after January 19`', 2018 per ESSB 6091.
Applic'ant/Agent Signature
PART 2: Health Department Review (Staff Use Only)YES NO TAG# - Called In 5(27- 1 rr -z.. Fort 5!/
2_3'�3
❑ Driller on Site?
❑ Is the well capped and Vented? _ 3 U S
�' ❑ Is there evidence of a surface seal? GAS ; �, t �e
Sr ❑ Is there a 2" annular space on all sides of the casing? (�3 i(7 "l
❑ 'Has the seal slumped?
❑ Is the well flowing or is there evidence of other leakage?
❑ ❑ 094 there evidence of cascading water?
❑ ❑1.S.D Is there evidence that the seal is at least 18 feet long?
❑ Do the well site set-backs appear to be appropriate?
Comments (WtA k aoklAd-e S 2-3)
❑ Pass ❑ Fail Inspector
� 1106141, 5-,iri4 Date , f L 23
\-7,) ,...1r This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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