HomeMy WebLinkAboutWEC2023-00064 - WEC Application - 6/5/2023 ' 1 1 1
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MASON COUNTY JUN p 5 2023 415 N 6T"STREET,SHELTON,WA 98584
SHELTON:360-427-9670, EXT.400
�' COMMUNITY SERVI BELFAIR:360-275-4467, EXT.400
ELMA:360-482-5269, EXT.400
Boiling.Planning,Envnon mental Health Community Health
ey 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 a3 - 2. Attach a plot plan and vicinity map.
. — 0 Cash 3. Submit this completed application with appropriate fee a minimum
0 Check of 24 hours in advance of initiating well construction. Refer to
�� Mason County Environmental Health fee schedule for cost.
O 24 Date of Payment//(-Y /5(c3 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant I Parcel Identification
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Site Address y 21 V J 1 A h Wail z Q,,e I i Pal or. Start Card# W f S28
(02_
Drilling Firm V ic, Vr 1 1 t / Phone 'j[00- L1 r 5-3(e 7
Applicant JC1Nt1 i&nlivY�1'1 7� Phone LI'S q/2• -
Mailing Address WiI VV /UG��v/U�{'1 -g�--� l>, or 36,hoiag €(.3 ADd .COvin
City I A-U Y1 State Vv ► ! Zip 13 4
Parcel Number S 20 0 cQ 1C 00 3 1 l
Directions to Site (O i VJ Sh IDC --fJ\ —\-CA w . Na\ltv t"1i
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+0 S I t't d icv
Is the well site within 100 feet of salt/seawater? Dyes [%No L.-Q.('
If yes, a variance from DOE is required. Have you applied/received (circle one)a variance? Oyes [jINo
NOTICE:A/I proposed connections to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled after January 19m,2018 per ESSB 6091.
Applicant/Agent ignature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In !0/2 t l 22> few__ (#. 3
❑ ❑ Driller on Site?
❑ ❑ Is the well capped and Vented?
❑ ❑ Is there evidence of a surface seal?
❑ ❑ Is there a 2"annular space on all sides of the casing?
❑ ❑ Has the seal slumped?
❑ ❑ Is the well flowing or is there evidence of other leakage?
❑ ❑ Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long?
❑ ❑ Do the well site/set-backs appear to be appropriate
Comments / 'I Sp1 ( r ��
J _En
❑ Pass ❑ Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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