HomeMy WebLinkAboutWEC2017-00135 - WEC Application - 12/29/2017 DEC 2 9�2011 lJl/ MASON COUNTY
e Ndln%PlenninSEmirmmentelHmlth,Community Heakh
415 N 6r Street, Bldg 8, Station WA 98584,
Shelton: (360)427-9670 ext 400 -- Belf0 �87xt 400 v Elms: (360)482-5269 ext 400
FAX(38 )42
NOTICE OF INTENT TO CONSTRUCT A WELL
permit Number Payment Information In ns
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number 2. Attach a plot plan and vicinity map.
❑a Cash 3. Submit this completed application with appropriate fee a
1T!Check ., / minimum of 24 hours in advance of initiating well
GG f ( y24 ( construction. Refer to Mason County Environmental Health
Date of Payment ( I fee schedule for cost.
4. Mason County Public must receive notification at least 24
hours prior the drillin of the well.
PART 1: Applicant I parcel Identification I ` n c1
Site Address I Ub`) 111! I Start Card# we a"1/� —1 J\
Drilling Firm Phone
Applicant Phone
Mailing Address p
CRYS4,14"M rt)�f State W-4 Zip / &522
Parcel Number3gQnt'1 s? ooco 7 /O Q�
Directions to Site SE 61 D /F/IZA dR
Is the ell site vrithin 100 feet of sak/se Wer Yes No t V Z r Au N¢r Z 1 1� 1
If yes, varia D fired. Have you applied/received(circle one)a variance? Yes N 17,4 J-
Applicant/Agent bignature �
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❑� 11 hxaArA
❑ Pass [IFail Inspector `y Date
This form may be scanned and available for public view on the Mason County Web site.
J:EH FonnstDR]NRING WATER FORMSThinking Water Notice of Intent to Construct a Well.docx Revised: 120/2017
' E�
500 p6 9g 54
-
�i: a6.54. a C
-
1 �
y40 ti o O
42
L
e UCA
p� N
r f 10
n
r
'r u 100 -
� n
41 �9E)�0C3� ED
a d. 1, •'k
co t '
m
a
I' 1 NOT. E.e.,iEO
- D
S F.' w m
— VO/
r o
It
�• 2 • !._e 4. ifs \ -'? -- — � Oa �Y i
,ts m . 5
Y Y d iO • - _ W
Aii
ij
n ! mD
I.
;O' NOT,ILAiTEO _
- . 3 •+mastic ss;� e