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HomeMy WebLinkAboutwec2024-00047 - WEC Application - 3/18/2024 MASON COUNTY COMMUNITY SERVICES BUIIdnePWnNatnYlrmm�nalfMMM,Comnunxy H�a1N AE BY.__C —'IL -- 415 N 6Y Street, Bldg 8,Shelton WA 985a4, Shelton:(360)427-9670 ex[400 4 Beffalr.(360)27SA467 ext 400 0 Elma:(360)4825269 ext 400 FAX(360)427-7787 NOTICE OF INTENT TO DECOMMISSION A WELL Permit Number Pavmerd Information Instructions 1. Complete Part 1. Incomplete applications will be rejected W EC Receipt Number jCgR& S 2. Attach a plot plan and vicinity map. 20: / r ❑ Cash 3. Submit this completed application with appropriate fee a nr` Check minimum of 24 hours in advance of initiating well OW� :Da. decommission. Refer to Mason County Environmental f Payment 34B129 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 Site Address 3-11I s£ f+y� d'Q IaG' SGG�Yotai W/# Stan Card# r1,f}ESlfl7S Drilling Firm . WC �I , ( µ.u.i io Phone orfS% 36U- q1�-`I371 Applicant "C,64 Phone H Mailing Address 7id11 % ,f}yr o( 'a (Rd City C,10 �DA State r,✓,+ Zip :,I ItTR-4 /1 Parcel Number 0.1 33 u Directions to Site � � n� rR� hj lea 6,4 1, '57E r) E^ (it ti u SQ a 6 oqez/ Is the well being decommissioneded to to allow sitingAf potential source of contamination(its.septic dreinfleld)? ❑Yes MNo If yes,a variance fro DOE' guired ave 7applied/received(circle one)a variance? ❑Yes ❑ No Applicant)Agent Sig attire PART 2: Health Department Review(Staff Use Only) YES NO TAG# Called In ❑ ❑ Driller on Site? ❑ ❑ 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? Method of Decommission and Comments ❑ Pass ❑ Fail Inspector Date This form may be scanned and available for public view on the Mason County Web site. JAEH FormsIDRINKING WATER FORMS\Drinking Water Notice ofintent to Decommission a Well.docx Revised: 1/20/2017 Yr S m kAlkw10 )�P r t � - t� �t i _ r MASON COUNTY COMMUNITY SERVICES Building.PNnnYg.EnvManmerxJ Nailrk Conmunlry Health 415 N 61°Street,Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext 400 4 Beffer:(360)275-4467 am 400 G Elms:(360)4825269 ext 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 Number 2. Attach a plot plan and vicinity map. ❑ Cash 3. Submit this completed application with appropriate fee a ❑ Check minimum of 24 hours in advance of initiating well decommission. Refer t0 Mason County Environmental Date of Payment 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 Site Address Sat( S� AVM bra �cl' S�E�ta-siW/# start Card# /tom/f{7S Drilling Firm )ZQ Well �C,O1u+PariSCioln l�01 Phone r,� 360 ^ Applicant ! -�Vv-d 7�rn �yl%I J Phone E6 d O �O A UN Mailing Address �dli S'L of Avt 'a (Rd City 0 4no State fn/A- Tp C/ lm-el Parcel Number 2a 01 3 3 0 `1 / Directions to Site ISE nyc,r /U I wll lC I0 oral Off �� vnA �m�LG r� �Le, abeH� �(ftll LLu L (it a w SQ Is the well being decommissioned to allow sitin f potential source of contamination(is.septic drainfield)9 ❑Yes ErNo If yes, a variance fro DOE Is r Juired aver applied/received(circle one)a variance? ❑Yes ❑ No Applicant/Agent Si ature Y PART 2: Health Department Review(Staff Use Only) YES NO TAG If Called In 3 l4 2-`1 6e,* A I s ❑ M Driller on Site? Has the well been decommissioned in accordance with WAC 173-160? �I Is this a cased well? bQ 5 W.6U ❑ Is a well report available that shows a surface seal? Method of Decommission and Comments ❑ Pass ❑Fail Inspector Date This form may be scanned and available for public view on the Mason County Web site. ]:\EH Furms\DRINKING WATER FORMS\Drinking Water Notice of Intent to Decommission a Well.docx Revised: 120/2017 114, ----- - �Y P 40 - -- R < N T ■i T'q -