HomeMy WebLinkAboutWEC2024-00033 - WEC Application - 3/21/2024 (2) )� �IId�
�111 4'IS N BTM STREET,SHELTON,WA 98584
MASON COUNTY S FEB 0 SHELTON:380.427-9670,EXT.400
COMMUNITY SERVICES 23 2024 BELFAIR:360-275-4467,EXT.400
ff& ELMA:360482-6269,EXT.400
BY FAX 360427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Pormit Number " pavment IMonnalbn InsWetlona
- Complete Part 1.land vicinity
applicationsap will rejected
WEC Receipt Number 2. Atlefi a IS plan andvicinity map.
❑ Cash 3. Submit MIS completed application win appropriate fee a minimum
Check of 24 hours in advance of initiating well censtruction. Refer m
D0033/�� �y Mason County Environmental Health fee schedule for cost.
Dale of Payment 2 mS 1 4. Masan County Public must receive n0i fu ation at Isast 24 hours
prior m the drilling of the well.
PART 1:Applicant I Parcel Identification
Site Address ^So 1 (f Start Card If �� s-�A�
Drilling Firm ��j�/�A �S t I r I Phone
Applicant $Z LLft f ijje6 S Phone
Mailing Address Af —ILl'14/1191 SIC1c! Snl
CRY n./ 01 State LAI11V Zip 9os—al` 1
Parcel Number o —y-7 �N'()ot)140 �L /�
Directions to Site 10e+Vn9A41 AdIJ46, lln Li�A \1 e4i 1,ti+-* ran N (3 ay R41.
Is the well site within 100 feet M sell/seawater? ❑Yes K INo
0 yes,a variance from DOE is required. Have you applied I received(circle one)a variance? ❑Yes $No
NOTICE:All proposed cos donrfonewwallaaresubjectmwahradequacymqulmnrenfaetdareotbudding pamM per Masan County TNe6.8a
Weteruaage realrlctlona endaddib'anee her may apply m ad new water dnllad after January f9'^.W18 per ESSB 6M.
t31iwuz't
Applicant I Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In 3 ll L`I F ; 12— 1
❑ Driller on Site?
❑ Is the well capped and Vented? g
$L ❑ Is there evidence of a surface seal? aj
❑ Is there a 2^annular space on all sides of the casing? .1 O
Has the said slumped?
❑ Is the well flowing or is there evidence M other leakage?
❑ ^� Is there evidence of cascading water?
❑ Is there evidence that the seal Is at least 18 feet long?
l7 ❑ Do the well site set-backs appear to be appropriate?
Comments
ass ❑Fail Inspecr Date j7 )4
This form may be scanned and available public view on the Hawn County Web site. Revised:2/7/2018
Mason County WA GIS Web Map
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