HomeMy WebLinkAboutWEC2023-00080 - WEC Application - 4/3/2023 '
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O1 �M4 5 N 6TH STREET,SHELTON,WA 98584
MASON COUNTY , nr SHELTON:360-427-9670, EXT.400
071 ,
COMMUNITY SERVICES �J /'l '‘ u `s ' ` --' L BELFAIR:360-275-4467, EXT.400
ELMA:360-482-5269, EXT.400
, Building,P4mning,Environmental Health,Community Health
BY: 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 2. Attach a plot plan and vicinity map.
rn� t\ 0 Cash 3. Submit this completed application with appropriate fee a minimum
c�CL b[JCoi L,1 Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment 141113 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 / 7`/� Z- )27 ..)o h ..a kk AV. Start Card# l,J. S.Z 2 Z /
Drilling Firm ArA„,-21jv,.,, /4// Q,-, //, ,S Phone j5;3---53 y- 731E
Applicant be/sal c/o /QiULz.norol., �, ..!),.//, Phone me 7`a1=`j o 7 9
Mailing Address /D.0 , ig 0 ,"-ii 7
City --7-;:), 44.:/inra State 4>� _ Zip ycf•-yyde- ,
Parcel Number ,?,24.?y.-„I3 ._ yOo}O
Directions to Site 6-,,r1 s/€/fo a.,., /,/w 3 )'!lest.-., I Ae Al / f At/ c e Av„-�---
f'r«i>e.-n�,/ tt'r d'i'L, . , Z-��,✓" ..«.t' Art-.
Is the well site within 100 feet of salt/seawater? ❑Yes 161No
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 usa restrictions and ad nal 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 Z 'Zt ( Z3 F:a 't(ZZ
❑ p Driller on Site? 3 fy 0 `611-1
Er ❑ Is the well capped and Vented? \'-‘ ZbLA,S—c)
.Er ❑ Is there evidence of a surface seal?
-0 ❑ Is there a 2"annular space on all sides of the casing? - l Z3 • e S Gbos
❑ .0' Has the seal slumped? r
❑ Is the well flowing or is there evidence of other leakage? ¢
❑ Er Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long? ►- ' og JCS +
2' ❑ Do the well site set-backs appear to be appropriate?
Comments 1.6---F-f MC---;'.) B1zi u ER -tom c c- c r 41 1112.3 r
Pass ❑ Fail Inspector Date ,�f 3 23
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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