HomeMy WebLinkAboutWEC2024-00006 - WAI Health Waiver - 1/2/2023 h 415 N 6TH STREET,SHELTON,WA 98584
MASON COUNTY SHELTON:380427-9670,EXT.400
SELFAIR:360-2754467,EXT.400
COMMUNITY SERVICES ELMA:360482-5269,EXT.400
FAX:360427-7767
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NOTICE OF INTENT TO CONSTRUCT A WELL
Inst actions
Permit Number P vmantlnformation licatons will be rejected
qq�a�.. 1. Complete Part 1.Incomplete aPP
Receipt Number `4N-'—s 2. Attach a plot plan and vicinity map.
C 3. Submit this completed application with appropriate fee a minimum
❑ Cash
.)%0 ❑ Check of 24 hours in advance of imitatingwell construction. Refer to
Mason County Environmental Health fee schedule for cost.
d 0000 Date of Payment �� "` 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART t:Applicant I Parcel Identification
Site Address (l^ Start Card
o r
Drilling Finn Phone
Phone
Applicant
Mailing Address alit
City
State _ ZIP
Parcel Number
Directions to Site
Is the well site within too feet of salt/seawater? ❑Yes o
7 re
If yes,a variance from DOE is required. Have you applied ceived (circle one)a variance? ❑Yes)RNo
NOTICE:AN Proposed c nec' sto new wells are subject M wateradequacy requirements at Ome ofbuiping pert,#per Mason County TO see.
Water usage tea r tl#io�M/fees may apply to all new wells drilled aRerdenuary 19a.2018 per ESSB 6091.
gat: W, toll 936
pplicent/Agent Signature Lon '.-II). 06(Pall
745 : W 7(3
PART 2: Health Department Revises(Staff Use Only)
YES NO TAG# G lX3 called In
❑ Driller on Site?
Is the well capped and Vented? M1
❑ Is there evidence of a surface seal?
❑ Is there a 2'annular space on all sides of the casing? �� F
❑ Has the seal slumped?
❑ (� Is the well flowing or is there evidence of other leakage?
_t ❑ Ia there evidence of cascading water? /1
A*W S ❑ ❑ Is there evidence that the seal is at least 18 feet long?
ffi ❑ Do the well she set-backs appear to be appropriate?
Comments 3 2-PA4 lu£u J TRf LLCd oA( Zosl • 10_4V-r
Pass ❑ Fail Inspector Date
702.
Tim,form may be scanned and available for public view on the Mason County web site. Revued:2nnoi
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