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.
I:IEH FormsIDRINKING WATER FORMStDrinking Water Notice of Intent to Decommission a Well.docx Revised: 120/2017
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