HomeMy WebLinkAboutWEC2016-00022 - WEC Application - 3/28/2016 �NSON COLrIV
MAR 2 9 2ois Public HMth
Mvars woM1 for a We, hwiNer Macon county
415 N 6'Street, Bldg 8, Shelton WA 98584.
Shelton: (360)427-9670 ext 400 0 Bey (3 �87 xt 400 4 Elma: (360)482-5269 ext 400
FAX(360)42
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment lnfor?ration Instructions
�y �p 1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number •-icfs 2. Attach a plot plan and vicinity map.
V-�11 ❑ Cash 3. Submit this completed application with appropriate fee a
S.L-�dL Check minimum of 24 hours in advance of initiating well
CAoaa �J., ����� construction. Refer to Mason County Environmental Health
Date of Payment lri7 ho fee schedule for cost.
4. Mason County Public must receive notficetion at least 24
hours prior to the drilling of the well. -
PART 1: Applicant/ Parcel
Identification �/J' pp,�V,,r,�jJ�"�`��
Site Address IU,3 W�j EW i2�� 'f wI e�sd`- Start Card# tl��� e a35'y���
Drilling Firm Q-..r • ai ADVAn/ e'En Okf tHe: LLC Phone %, .AQ3�-2ZW
Applicant Z),D(,G,,y � PAT011.9 rdi n-.c r,lLA-M Phone 4TOE G 9 a
Mailing Address 204 Ntdc /va' REQG P Ll -
city /L crr. F Gdre.< State 1s1A Zip 94/4 /
Parcel Number /'a oc p f'! 600 20 -
Directions to Site wr n.v o .des
Is the well site within 100 feet of sett/seawater? Yes No -ra.rn P_ eK/MA Lojy:.� red,
fl yes, a variance from DOE is required. Have you applied/received (circle one)a variance? ❑Yes ❑No
A pli a Agent Signature
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 Bowing 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 aLPa� �n5
❑ Pass ❑Fail inspector Date
This form may be scanned and available for public view on the Mason County Web site.
MEH FormstDRINKING WATER FORMStDrinking Water Notice of Intent to Construct a Well.docx Revised: 121l/2015