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HomeMy WebLinkAboutWEC2022-00166 - WEC Application - 12/14/2022 *-, `. r�N\ MASON COUNTY 415 N SHELTON: 360-427-670 EXT.400 H) COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400 � — ELMA: 360-482-5269, EXT.400 r ,,s Building,Planning,Environmental Health,Community Health '' ___ 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. �l� ❑ Cash 3. Submit this completed application with appropriate fee a minimum 11 —�,�� Check of 24 hours in advance of initiating well construction. Refer to / 1, Mason County Environmental Health fee schedule for cost. Date of Payment�2/I_1120. 4. Mason County Public must receive notification at least 24 hours prior to the drilling of the well. _1 PART 1: Applicant/ Parcel Identification tt Site Address 429P r,ib el- T.'d e..5 a. Start Card# �7 419f Drilling Firm C cp m1 Lvw4-e I— 0 e-'•`) I I1, -1=I'iC , Phone 3 6'.. g3 f9 ()toms— Applicant / ,i`/ y, y�5 ,`)i, eii,$ Phone g(�r- �c9, -J9 0 Mailing Address q/4' /7/oI ley 4" y �,4. /® / /1 City MI12t`L'i V e State in/. s�Zip 3 /l..2-2 Parcel Number .3 . ac 9 73 ' )Z, Directions to Site Is the well site within 100 feet of salt/seawater? ❑Yes Lf46 � If yes, a variance from DOE is required. Have you applied/received (circle one) a variance? ❑Yes IINO NOTICE:All proposed connections to new wells am subject to water adequacy requirements at time of building permit per Mason County Title 6.68. Water usage restricti nd additional fees may apply to all new wells drilled after January 19m,2018 per ESSB 6091. Applicant/Agent Signature PART 2: Health Department Review (Staff Use Only) YES NO TAG # Called In `i(2 /2-) i=,q_ Y(Zti/ �-3 ❑ ❑ Driller on Site? ❑ ❑ Is the well capped and Vented? ❑ ❑ Is there evidence of a surface seal? Co E,=)-g r) ElCIIs there a 2" annular space on all sides of the casing? o b ❑ CI Has the seal slumped? c-�m ❑ ❑ Is the well flowing or is there evidence of other leakage? 21/2 ❑ ❑ Is there evidence of cascading water? _‘--• i;=3 t, ❑ ❑ Is there evidence that the seal is at least 18 feet long? o 11 ❑ ❑ Do the well site set-backs appear to be appropriate? �ir � - Comments ❑ Pass ❑ Fail Inspector Date This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018 • . 'a • g �� $ tt ii �o i I Q ° x I1dilliiii ..i Z �I �" �— s 0) jM CZw •I 1.ikjiZ J Co (gvJ f.:: U U � (f) Z g E TIMBER TIDES DRIVE W� W o � 165.00' ; � Q N w FW- --i a N CO 0b CO iD I I I N Z Cn cC H o % W J O M\ 2 W — \\ BUILDING ENVELOPE m Ali � - c.") 2 N i CV PPOED 11� r , "o ii W —.0- `s < Z ‹ I- ....:. i 1 i11 Yz \ •\ 1' l Z h ,�/ I i4 Z ;:1; WOLC inj TO WELL W no0 g Q X W ' ` ` W O 8 n P. . . M fi 0 0 0 l h < i AIL 111. / I. ZZ CC - '�Em PROPOSED i -r >a 0 4-BR HOUSE WO P. Z C°z z ;°1. 0 0 ', , to,Lfiu11tS Q�` 0 F O 11- d I 0 p �,z,z,�� .O E' Et1SEMENNTT IW ° pp? ° m {�;j Z7`� L ,"--,-rl�.. O. ../ ND 1 z?i-0 • Itl Y z WC © • Qt i 1i10 ° ) o< i e Q J 14 0o i( ( `i m r 2I 1 ° •z C P oom mz 10'NO BUILD ZONE Jh j h L I i F. 0 00 n y o 2 p m 1 n`' mOlFljho> p j CrF2ppr 3 �Q ? Oo0° i 0 a_ Orr 0D a ¢ Cm0° W Oa IhZI°tl p .. . g tsi 2Q r OO�m rmrp ®ZF�zr o ,� ` h ° °CZC r00i0m ,'�h 2 Y h r f m< 01.011} III? os ttl III ��� SL3 `,, �W a Bd,°CC¢Zrpm (UOh�F I w W2za°orm�a a0 LQuiiQ 0 ti p0 5 rmo (It ° t00% IV 43 F z>0miseomi>CmayLohvm RESERVE OQ U FWmU° lZ(yWarWZ°WIoE Woe°jcrl�z�i<�oamcu2ogLggqzm AZ NII6FLCIVii<O0Zi60— F' ''I''. '0 Oi J J gc�mOCZ �,Fp<02LL �a0tyl •''50.7-- 4 Q, . 000t di,zE70.aaaj1z'0°mzh z Dl 0 MALIENIJATIONZONE 165-.00 < WFJzmmC(Di miOUFmZ ro L 3 CC h prymzmCmiD:11/ lIO" zSr u°h OW Joj3"-mpmO t b 10 illW4QUZ42011rf- ZC yy _ a1. u 3 V 3 acFzolleiroiiowipmfIi% a 1 t Q1 niotikrntm®t.FFi�z(o 2 ImIJ3E°ICh070 �3Cr� °Fz , ouz(ioz1-z3e,.umuzZ02°r m .1 I°Z0@()D°Z1-50i60°P! SS 3 h t 7 U 7 g 7 I FzuIK(0011! (JX1(W11( - -a000Lz0005Lau3FmoS5