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HomeMy WebLinkAboutWEC2023-00118 - WEC Application - 10/4/2023 415 N 67x STREET,SHELTON,WA 98584 MASON COUNTY SHELTON:360-427-9670, EXT.400 COMMUNITY SERVICES BELFAIR:360-275-4467. EXT.400 e„as„g.vw.,.e,e�ea�n.nxwx.ca .gxwn ELMA:360-4825269,EXT.40D FAX:360-427-7787 NOTICE OF INTENT TO CONSTRUCT A WELL Permit Number Payment Information impbrictions � 11 IIII 1. Complete Part 1. Incomplete applications will be rejected WEC Receipt Number ttIIY 2. Attach a plot plan antl vicinity map. ❑ Cash 3. Submit this completed application with appropriate fee a minimum -ti — ❑ Check of 24 hours in advance of initiating well construction. Refer to U(J A [] "_ O Mason County Environmental Health fee schedule for cost. CJ pate of Payment 1 - -� 4. Mason County Public must receive notification at least 24 hours prior to the drilling of the well. PART 1:Applicant I Parcel Identification Li //1/,,,, ,, /I -- .�c\ Site Address ' 3y20_E4 -S 11-66,t m z1 Jt- Mdgc""�4 Start Card. W�%S'k.�4 S Drilling Finn Noe W ae �D..&4."( �T Phone �1'8"3007 Applicant oojia L-r-.O, Phone ?I&-5W-4672 Mailing Address 2Z Sc 1"vef @at city �_a6Rvin, State Wpi zip 460'k Parcel Number su24-51-4yqoq ff���� A,1 Directions to She �n avt �� t0. OT U "{' i Is the well site within 100 feet of salt/seawater? ❑Yes 410 If yes,a variance from DOE is required. Have you applied/rrecelved (circle one)a variance? ❑Yes*No NOTICE.' propoa dto ISM new walls are subject to wateredequacyrequiremanla at"ofbuddino parmttper Macon County Tida e.88 WarerusItlorral fees mayapply to all now wells dolled after January 19'.2018per ESSB 6091. Appillosht/Agent Signature PART 2: Health Department Review(Staff Use Only) !,,' YES NO TAG If FYI Y / Called In ❑ Oriller on Site? ❑ ,❑- Is the well capped and Vented? ❑ Is there evidence of a surface seal? _ AEr' ❑ Is there a 2'annular specs on all sides of the casing? _ I .�.; PW VI \ LSD ❑ ❑ Has the seal slumped? a , P, D Is the well flowing or is there evidence of other leakage? I 0 4 2023 ❑ Is there evidence of Cascading water? ❑ Is there evidence that the seal is at least 16 feet long? ❑ Do the well site set-backs appe to be appropriate?/ -- Comments -i s yy _Q'Pass ❑ Fail Inspector Date �� L' V This form may be sunned and available for public view on the Mason County Web site. Revised:2/7/2018 ) � � \ ■ , ;§ / f � \ » m ( � w . i . - Q lie ! $ / , /, \ \ ;P '050 - � . . / ` n | a _ § § ° Q loll ) ` f ! ( | � } � ■ a |, �§ i OZ + tC Iy oCL�ZG ! « © - _ WOM,?MU;