HomeMy WebLinkAboutWEC2023-00126 - WEC Application � �II���
BUJ 415 N 6TM STREET,SH 27-967 ,E 98584
MASON COUNTY OCT 17 2023 SHELTON:360J27-9670,EXT.400
COMMUNITY SERVICE BELFAIR:360-275-4467,EXT.400
oac.,yvr.,�.,vE,wmnarnx.xnco,,.,iwnxya, ELMA:360-082-5269,EXT.400
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 mot, Receipt Number ;L5 2. Attach a plot plan and vicinity map.
�j23 gull ka ❑ Cash 11 3. Submit this completed application with appropriate fee a minimum
Check of 24 hours in advance of initiating well construction. Refer to
q Mason County Environmental Health fee schedule for cost.
Date of Payment I O 1l "r 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1:Applicant I Parcel Identification
Site Address lgOl /p _ Start Card#
Dolling Firm GQ7G/ify/.TY_/w rD" Ali rth9 / Phone 3Gt'-�f30-%d19rJ
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Applicant 4 rlh Off-, el-,, , .tn�� Phone 7�if-�3�i�- 1e3L3
Mailing Address �LJ r� e' ��Ar' PVV `.- 'ItI-Q
city state *0'� zip �2
Parcel Number 302-�,�y 7r�9d1 y,,,/y
Directions to Site 0.6 �M6wtrc Ro I lrh%1 tC L oN-r PIET' ,JlhT l wr
c garacR
Is the well site within 100 fast of salt I seawater? ❑Yes No
If yes, a variance from DOE is required. Have you applied f received(circle one)a vadance? ❑Yes []Flo
NOTICE:All proposed coon ins to new walls are subject to water adequacy red.,eme,ls at time ofbuildirg permit per Mason County Use 6.6a
Wear,usage restriction^ dagrlal may apply to all new wells drilled ader January is-,2018 per ESSB 6091,
Applicant I Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In
K ❑ Driller on Site? I`
❑ ❑ Is the well capped and Vented? f-AT: 4i, �{3Ty S 55
Q°j& ❑ ❑ Is there evidence of a surface seal? Lon[6- ;
.4� ❑ ❑ Is there a 2"annular space on all sides of the casing? �t
❑ ❑ Has the seal slumped? E
❑ ❑ Is the well flowing or is there evidence of other leakage? 114�
❑ ❑ Is there evidence of cascading water? 4�
❑ ❑ Is there evidence that the seal is at least 18 feet long? O
JR .r❑ Do the well site set-backs appear to be appropriate?
Comm sntq%� 1641 LzQ rl&T SS9 RT b
❑Pass ❑Fail Inspector cfc r(,,-,,,e-r t " 4N1- Date
This form may be scanned and available for public view on the Hawn County Web site. Revised:2%7/2018
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1. Proposed residence Q
2. Audio/visual alarm
3. 1200 gallon concrete
septic tank
4. 1200 gallon pump
tank with two risers M
5. Transport line
6. Valve Box y
T Primary/Reserve Drainfield 3 d YF wu,L ;
50'x55' envelope J `I` "sFp oesic"Frs
& Clean out ""
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9. Proposed Well Q
10. Waterline r P R 0 E
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Printed From Mason County DMS
Printed from Mason County DMS
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