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HomeMy WebLinkAboutWEC2023-00084 - WEC Application - 7/21/2023 p lJ I1 �tJ 45 1 6TH STREET, SHELTON,WA 98584 t111,04 \ MASON COUNTY SHELTON: 360-427-9670, EXT. 400 ^ COMMUNITY SERVICES JUL 21 2023 BELFAIR: 360-275-4467, EXT. 400 • L ELMA: 360-482-5269, EXT. 400 ' t Building,Planning,Environmental Health,Community Health _J FAX: 360-427-7787 cey NOTICE OF INTENT TO CONSTRUCT A WELL Permit Number Payment Information Instructions 1. Complete Part 1. Incomplete applications will be rejected �V� WEC Receipt Number2O 3-O O 1 2. Attach a plot plan and vicinity map. V 3— j���(�Q,(� ❑ Cash 3. Submit this completed application with appropriate fee a minimum l J��JC)�l 0 Check of 24 hours in advance of initiating well construction. Refer to C f•611/4- -3,ht 2 I3 ty Environmental Health fee schedule for cost. Date of Pa ment i4. Mason County Public must receive notification at least 24 hours prior to the drilling of the well. PART 1: Applicant/ Parcel Identification Site Address 14.0, VV \( - Q 1c1 l t Start Card #Drilling Firm Firm Lt(ye_r`�e.. 00\r\_5 'pu,A.A �)trak:t.‹., Phone (2- aL-3 YDS Applicant try' 1 �j-� T1���, 6 Phone Stop- 53(3 3(601 Mailing Address `AJ\ 11) tACt��it,0 City -AkAA.(,` State Zip ctLP) 5 (--tr1 Parcel Number (,12034- 3'.Z- 0 aC)00 Directions to Site Is the well site within 100 feet of salt/seawater? ❑Yes jRno 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 usage restrictions and additional fees may apply to all new wells drilled after January 19t",2018 per ESSB 6091. Applicant/Agent Signature PART 2: Health Department Review (Staff Use Only) YES NO TAG# Called In 7( _11Z3 Ec2 -1I2it (23 ❑ ❑ 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(,rof la3ece-t- ❑ Pass ❑ Fail Inspector Date This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018 / 4 Mason County WA GIS Mason County Horr / ,m; c!� Rl` ue, v e 1r 620343200000 X 0%111 Show search results for 62034... 439 ft 0 0 62 0 -32- lXic) e 1 600ft