HomeMy WebLinkAboutWEC2024-00039 - WEC Application - 3/11/2024 r Ir1,- Sq 415N6-STREET, SHELTON,WA 985M
MASON COUNTY SHELTON:360-427-9670,EXT.400
0 COMMUNITY SERVIC , RELFAIR:360-275-0487, EXT.400
ELMA:360.482-5269,EXT.400
aar.,sn..wo•.a+K»+adu.c�....y'br' FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment lnlorelation Instructions
1. Complete Part I.Incomplete applications will be rejected
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WEC Receipt Number a�-1 2. Attach a plot plan and vicinity map.
9 U1� ❑ ash 3. Submit this completed application with appropriate fee a minimum
-9 Check of 24 hours in advance of initiating well construction. Refer tpr•
p ' 11 Mason County Environmental Health fee schedule for cost. q.
�()u ` Date of Payment �C. 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well. I�
PART 1: Applicant Parcel Identification "IAQY11tBs(!$}V1)1I$11tlI C(7R1p 17 y1
Site Address �7c�p Q �N �A�1�R�I �� ji gm M iq �t Start Card# Yt1 C. pSsiSOS
Drilling Firm .�,,�1'. Phone
Applicant l6,y�
--OJr-t-�-�- Phone �lJ CRO ab -
Applirant y11Q'1K1�
Mailing Address 61"
City h I iHOY) � State � Tip
Parcel Number ,p - - CSJ000
Directions to Site l {�f( 0� It II �d M del YW�Vq�P Qd 1J «rl
Is the well site within 1 feet of)sat/seawate ❑Yes 2SI40 �.rJ'
If yes, a variance from DOE is required. Have you applied/received(circle one)a variance? Yes 2"r+o
NOTICE.All proposed com9ctieas to new Walls are subject to water adequacy requimments at time a buildirg pertnepw Mason County Title 6.66.
Water usage msbictims and additional less may apply to ell rew walls united after January 19^,2016per ESSS 6091, hXAM q__1
*lOfw2inn gpe p II yl• 14(Poll 64 do U
Applicant I Agent Signature
PART 2: Health Department Review(Staff Use Only)
YEAS NO TAG III Called In 211-112-4 Fr4k 'i
❑ Driller on Site? II "n II � � //
❑ � Is the well capped and Vented? �. lo�G1/t,C/t 1
Is there evidence of a surface seal?
❑ Is there a 2'annular space on all sides of the casing? 04 91'94
❑ Has the seal slumped? n tYl
❑ Is the well flowing or is there evidence of other leakage? 0-
❑ Is there evidence of cascading water? u
El ❑ X, Is there evidence that the seal is at least 18 feet long? 77 14s
❑ Do the well site set-backs appear to be appropriate?
Comments lohl ?&RAV
'}Pass ❑ Fail Inspector Date 3/it)2-Lir
This form may be scanned and available for public view on the Mason County Web site. Revised:2/72018
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