HomeMy WebLinkAboutWEC2017-00089 - WEC Application - 8/31/2017 MASON COUNTY }
COMMUNITY SERVICES _AUG 2..82017
® Building Planning,Emiroomental Health Community HealM �.. ,
415 N EP Street, Bldg 8, Shelton WA 98584, `
Shelton: (360)427-9670 ext 400 < Belfair: (360)275-4467 ext 400 S Elma: (360)482-5269 ext 400
FAX(360)427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Psrmit Number Payment Information Instructions
1. Complete Part 1. Incomplete applications will be rejected
W EC Receipt Number �6 1� 2. Attach a plot plan and vicinity map.
❑ Cash 3. Submit this completed application with appropriate fee a
'F]_Check minimum of 24 hours in advance of initiating well
QOO p/ construction. Refer to Mason County Environmental Health g� Date of Payment ~�) fee schedule for cost.
4. Mason County Public must receive notification at least 24
hours prior to the drilling of the well.
PART f: ApplicantI Parcel Identification
Site Address 71 W Satsop Bridge Rd Stan Card# WE28879
Drilling Finn Advanced Drilling LLC Phone 360 273-7735
Applicant Val Nielsen Phone 360 580-5847
Mailing Address 2629 Aberdeen Ave
City Hoquiam State WA Zip 98541
Parcel Number 61905-75-00010
Directions to Site
Is th Hell site within 100 feet of salt/seawater! Yes No
If y a vada ce m DOE is required. Have yo applied!received (circle one)a variance? []Yes WhIo
AlbL A Q
plicantlAgent Signgn ure—T
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In --
❑ ❑ Driller on Site?
❑ ❑ Is the well capped and Vented?
❑ ❑ Is there evidence of a surface seal?
❑ ❑ Is there a 2"annular space on all sides of the casing?
❑ ❑ Has the seal slumped?
❑ ❑ Is the well flowing or is there evidence of other leakage?
❑ ❑ Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long?
❑ ❑ Do the well site set-backs appear to be appropriate? .(
Comments 14W nq 42 ,A -a'
'm
Gad w❑ Pass ❑ Fail Inspector Date
This form maybe sunned and available for public view on the Mason County Web site.
JAEH Forms\DRINKiNG WATER FORMS\Ddnking Water Notice of Intent to Construct a Well.docx Revised: 120/2017
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