HomeMy WebLinkAboutWEC2023-00056 - WEC Application - 5/25/2023 rpgr
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1 MASON COUNTY
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415 N 6'h Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 •: Belfair: (360)275-4467 ext 400 Elma: (360)482-5269 ext 400
FAX(360)427-7787
NOTICE OF INTENT TO DECOMMISSION A WELL
--1
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.
2-OZ3—OCOS6 0 Cash 3. Submit this completed application with appropriate fee a
0 Check minimum of 24 hours in advance of initiating well
�/7�t) decommission. Refer to Mason County Environmental
Date of Payment 51257 U Health fee schedule for cost.
4. Mason County Public Health must receive notification at
least 24 hours prior to the decommissioning of the well. _
PART 1: Applicant/ Parcel Identification Site Address y Z 1 W IVahWQ f ?&I Reac/t Dr Start Card # 4 E 7 g 11. fJ
Drilling Firm Pa It
Oft rf/My Phone 360- W0i- 1437s
Applicant a �� 1 Phone
Mailing Address NO PC; Oa( , eirm Rd
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City lie(Fair- State �� Zip ?o ZIP
Parcel Number SZ001-I50000 3
Directions to Site Is the well being decommissioned to allow siting of potential source of contamination (ie. septic drainfield)? ❑ Yes No
If yes, a variance from DOE is required. Have you applied / received (circle one) a variance? ❑ Yes ❑ No
Applicant/Agent Signature
PART 2: Health Department Review (Staff Use Only) /7�/
YES NO TAG # IS'7 p wg Called In 67[ Z( !�(/ -
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❑ Driller on Site?
❑ Has the well been decommissioned in accordance with WAC 173-160?
❑ Is this a cased well?
❑ W1'(4 ❑ Is a well report available that shows a surface seal?
Method of Decommission
and Comments ',HT l s 04 "Kole 11t, `
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Pass ❑ Fail Inspector _ Date 6/ 1'/ /Z 13'
This form may be sc ed and available for public view on the Mason County Web site.
J:\EH Forms\DRINKING WATER FORMS\Drinking Water Notice of Intent to Decommission a Well.docx Revised: 1/20/2017