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HomeMy WebLinkAboutWEC2024-00091 - WEC Application - 7/29/2024 MASON COUNTY � �II COMMUNITY SERVICES JUL 29 +In� Buildinry PlannirsEmimnmental Health,CommunityHealN 2024 415 N e Street, Bldg 8,Shelton WA 985M, .SheMan_3fi.1!1 7-9670 e#400 P Bellair.(360)275-4467 ext 400 O Elms:(360)4825269 and 400 FAX(360)427-7787 NOTICE OF INTENT TO DECOMMISSION A WELL Permit Number Payment Information Instructions 1. Complete Part 1. Incomplete applications will be rejected WEC Receipt Numbera� 2. Attach a plot plan and vicinity map. -,ap a q _ ❑ Cash 3. Submit this completed application with appropriate fee a 4t Check minimum of 24 hours in advance of initiating well (3C0(; ( decommission. Refer to Mason County Environmental Date of Payment Z T 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 I Parcel Identification /' ,/ .f Site Address SJ'OO/T�e hl /SS!i9A C%-ee X-L Start Card# 4,CkL 6 Drilling Firm C Br I Phone 3nqbQ 8---f30- 941:;Ar— Applicant r Pt eI.SB17 Phone Mailing Address 3 s City L [/G eL!/o State 1414_ Zip 9zu 7-2 Parcel Number oC y do 49,93 D Directions to Site -Aamok- S' 'e Al 7Le flh Or' Is the well being ecommissionsd to allow siting of potential source of contamination(ie, septic dralnfield)? ❑Yes *0 If yes, a vaqp6eftni DWis required. Have you applied/received(circle one)a variance? ❑Yes l.$.No Applicant/Agent Signature PART 2: Health Department Review(Staff Usss Only) YES NO TAG# Nt/`7 Called In -7I ❑ Driller on Site? 1—�Tfk ❑ Has the well been decommissioned in accordance with WAC 173-160? ❑ Is this a cased well? ❑ Is a well report available that shows a surface seal? FJy V Method of Decommission I S is r-rt and Comments 7,- L1A Pass ❑ Fail Inspector Date N/7q This form may be n and available for pubik Wew on the Mason County eb site. 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