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Home My WebLink AboutWEC2017-00058 - WEC Application - 6/28/2017 MASON COUNTY JUN 2 2 2017 COMMUNITY SERVICFE:____ ____ Building Planning Emir°nmental Health Community Health 415 N e Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 4 Belfair: (360)275- 467 ext 400 4 Elms: (360)482-5269 ext 400 FAX(360)427-7787 NOTICE OF INTENT TO CONSTRUCT A WELL Pem It Number Payment Information InsWctlona S/ -�G' 1. Complete Part 1. Incomplete applications will be rejected yJEC Receipt Number b 2. Attach a plot plan vicinity map. h C 1C- [I Cash 3. Submit this completed application with appropriate fee a `�• I Check minimum of 24 hours in advance of initiating well q�1'\ construction. Refer to Mason County Environmental Health wU Date of Payment�1� fee schedule for cost. 4. Mason County Public must receive notification at least 24 hours prior to the drillin of the well. PART 1: Applicant 1 Parcel Identification Site Address Lk-1 O (,t) F,+ 6,9A Start Card# Drilling Firm e Phone Applicant 'N, � ' In-<,t ( l�> ( � °Tonal Phone Mailing Address —�97l F 2k; I La,2ja Rd City d�- r-� state A_ Tp Parcel Number (o ' 11 .30 LF 4 q 0030 Directions to Site Is the well site within 100 feet of salt/seawater? Yes o If yes,a variance from DOE Is required. Have you applied/received (circle one)a varlence? []Yes ■No Applicant/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 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 16011 ElPass ❑ Fail Inspector Date This form may be scanned and evaiWble for public view on the Mason County Web site. J:\EH Fonns\DRINKING WATER FORMS\Drinking Water Notice oflotent to Construct a Well.docx Revised: 1/20/2017 F �� rtmeTAx� �Nrexnuua lwrslwnevvcF /�';� IRE PI : Y, EOR:PETEPB ATE:05 MAY"'T PMCELY:61%JYYB0NT0 OE$M PAGE GP g1 v W SCME:1".iW NORTHANRL ' � w O&l1NE CONSTRUCT10N.M. F 3 A pv W 8