HomeMy WebLinkAboutWEC2024-00014 - WEC Application - 3/18/2024 415 N 6TM STREET,SHELTON,WA 985M
MASON COUNTY SHELTON:360-427-9670.EXT.400
0 COMMUNITY SERVICES BELFAIR:360-275-4467,EXi.400
ELMA:360-482-5269,EXT.400
rwimwm`sa��n+"+ sc<�^•^m"^i'^ FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Parma Number Pavment Inbrmatlon Instnu
1. Complete Part 1.Incomplete applications will be rejected
WWE—Cs-- Receipt Number2&24• 2. Attach a plot plan and vicinity map.
t/V ❑ Cash 3. of24Submit uis completed of initiating
with aDProp chef.ate e a minimumt
�1 Check M 24 hours in advance of initiating well a sch dulef Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment I � 4. Meson County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1:Applicant I Parcel Identification a�
Site Address CO10JI E 1 of f` TA hV" Start Card#
�
Drilling Finn r7rs /Drk`( Phone
Applicant Sco Cal1YA Phone 16,0-73I -2-2:35
Mailing Address 611 -"nak F-ml15- Pit—
city 5�ejfgf ✓ State VV Zip
Parcel Number
Directions to Site t r� Poe 5 Ja AtE of m t`^Q�
Is the well site within 100 feet of salt i seawateR []Yes ONo
If yes,a variance from DOE is required.Have you applied I received(circle one)a variance? ❑Yes ONO
NOTICE:All pmposedcannectioms to new wells are subjoa to welerade uacy raquimmenls at time ofbullding permit per Meson County rev 6..68.
Wafer usage r,,,lc m and aadd ional fees may apply o el new wells drilled after January W,2018per ESSB 6091.
y ^
ln nature PART 2: Health Department Review(Staff Use Only)
YES NO TAG# _. Called In 418,b11
❑ ❑ Driller on Site? LAT;
❑ ❑ Is the well capped and Vented?
❑ ❑ Is there evidence of a surface seal? tTl
❑ ❑ Is there a 2"annular space on all sides of the casing? Rl
❑ ❑ Has the seal slumped? m
❑ ❑ Is the well Flowing or is there evidence of other leakage? r
❑ ❑ Is there evidence of cascading water? >
❑ ❑ Is there evidence that the seal is at least 18 feet long? (((JJJ
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments AID-r tAf5PEe-t�h
❑ Pass ❑ Fail Inspector __ Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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