Loading...
HomeMy WebLinkAboutWEC2024-00110 - WEC Application - 9/24/2024 �LvjJ�ry Zt N 6-STREET,STREET,SHELTON,WA 98584 MASON COUNTY ffflSSSn���) SHELTON:360-427-9670, EXT.400 a A V COMMUNITY SERVICES FcP 7 4 9P 4 BELFAIR:360-275-4457,1400 ELMA:360-482-5269,EXT.400 Pais'n4nnnin0.6^'�mme'YIXNII,CnnmunilYNrM 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 W EC Receipt Number 2. Attach a plot plan and vicinity map. ❑ Cash 3. Submit this completed application with appropriate fee a minimum Gst�L-sal-0 �( Check of 24 hours in advance of initiating well construction. Refer to Mason 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 1 Parcel Identification .-I p Site Address y2 02-33- OL Ol Start Card# VFS wg Drilling Finn meeR Ke-V-S PNH-0d--DRr 11 tnG Phone 966-ij Y8-38dS Applicant OO Cn¢- Me Phone -�6D J'/moo Z. Mailing Address L-11 3 City State LJ Zip Parcel Number yob uZ- _ 00 ) n Directions to Site 1404 P ytorl 741421d � R. � o✓t ft���f j^" I r,1� -(-0 1-Eov%e�y S ct-e k t��c Is the well site within 100 feet of salt I seawater? []Yes �Bmo If yes, a variance from DOE is required. Have you applied received (circle one)a variance? []Yes gNo NOTICE:Allproposed connectrons to new wells are subject to wafer adequacy requirements at time of building permitper Mason County Title 6.68. Wafer usage ' sons end eddib"I tees may apply to all new wells drilled after January W,2018 per ESSS 6091, Applicant) ent Signature PART 2: Health Department Review(Staff Use Only) YES NO TAG# Called In ❑i" ❑ Driller on Site? Ir(Ia(>� Fex rr �13 ❑ g' Is the well capped and Vented? ❑ Is there evidence of a surface seal? Er ❑ Is there a 2"annular space on all sides of the casing? ❑ L,,., Has the seal slumped? 4 1 L(, ( S 3 El -a' Is the well flowing or is there evidence of other leakage? ❑ ❑ Is there evidence of cascading water? lA a O, - y♦' ❑ Is there evidence that the seal is at least 18 feet long? j��'! ❑ Do the well site set-backs appear to be appropriate? Comments ji ass ❑ Fail Inspector Date This form may be scanned and available for public view on the Mason County Web site. Revised:2j72018 it O a ; z n § k 0 ) \ c . / \ { 0 ) | \ 0 .k ! � ® e � � e t = _ � § ( | �- ) { \ � \ � � \ � \ O O / ƒ c . \I cn /CD CD ! §N IF§ ° a ] � q § � ^ (a ! @ \ § � p � / \ ! ! -� \ 2 p ® - \ \ \ MMason County WA GI5 •-on County Homepage + o . , . . , o © to } Well head y` V. ^ �' r 1 A d� 3 4