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HomeMy WebLinkAboutWEC2024-00052 - WEC Application - 3/28/2024 E IMI N 6TM STREET,SHELTON,WA 98564 MASON COUNTY MAR 2 ' 21 SHELTON:360d27-9870,FXf.400 COMMUNITY SERVICES BELFAIR:360-2Ts-4467,Exr.400 r, ------ ELMA:360J82 6 EM. 87 wra�avw�ireenwa,.,W x«a.co-...axwn BY:___ 00 FAX 360 n-az7- e7 NOTICE OF INTENT TO CONSTRUCT A WELL Permit Number Pavmetd Information Instructions 1. Complete Part 1.Incomplete applicallom will be rejected WEC Receipt Number 2. Attach a plot plan and vicinity map. ❑ Cash 3. Submit this completed application with appropriate fee a minimum 911 Check of 24 hours in advance of initiating well construction. Refer to Meson County Environmental Health fee schedule for cost. Date of Payment 4. Mason County Public must receive notification at least 24 hours prior to the drilling of the well. PART 1: Applicant I Parcel Identli ostlon - Site Address Sr//J/ r /' rr L Start Card# (a/F sf7J6 Drilling Firm /f/G/`e-e/s-,, &)s// 11.. 421.e�i Phone EMT-CrJ7-73'� Applicant r Phone Mailing Address 10 O ,&;z Y2 .3-7 City "T State 42,E _ Zip Parcel Number 2 O 5/1 Directions to Site �y J s A {e-•e•/. /-/� �- G,.ruc fe /--/d- - Is the well site within 100 feet of salt/seawater? ❑Yes WO It yes,a variance from DOE is required.Have you applied I received(circle one)a variance? ❑Yes ONO NOTICE:AIt proposed connacfbna to new vrells are subject to wateradequacy requirements at time of building permit per Meson County TWO 6.68. W_afe`r}/�9�resMcb'onnsanaann�d addfional fees may apply to all new"Il drilled aRer January 19°i,2018per ESSB 6091. Applicant/Agent Signature PART 2: Health Department Review(Staff Use Only) t YES NO TAG# -h F u ti 7 Called In (o 7Y( toe Driller on Site? (y I fyl2'f' „� ❑ 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? l i{ -I . ZI o sb f r� ❑ „0- Has the seal slumped? Lor z _Er— ' ❑ Is the well Flowing or is there evidence of other leakage? 1 ❑ Is there evidence of cescading water? ❑ Is there evidence that the seal is at least 18 feet long? �` �' fiY ❑ Do the well site set-backs appear to be appropriate? ./Co-mments f � zY ass ❑ Fall Inspector This form may be scanned and available for public view on the Mason County web site. Revised:2/712018 § • ( �q | [ ! ` ( Hill | �] m( ) ƒ� ` § ® �} \ �\ 4 � | �. . . , . . . z. y . © 2 - �