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HomeMy WebLinkAboutWEC2024-00027 - WEC Application - 2/15/2024 MASON COUNTY 415 N 67H STREET,SHELTON.WA 98584 SHELTON:3W275-9670, EXT.400 COMMUNITY SERVICES BE ELMA:360482-5269,EXT.400 ELMA:380-482-5269, 400 s,u'.,yw,.,nsr--m.+H�m.c^^`^"�re"'°gym FAX:380<27-27-T787 NOTICE OF INTENT TO CONSTRUCT A WELL Peril Number Payment Information Instructions 1. Complete Part 1. Incomplete applications will be rejected WEW Receipt Number 2. SAttachubmit a plot plan and vicinity map. aril' Cash 3. Submit this completed application with appropriate fee a minimum Check of 24 hours in advance of initiating well construction. Refer to qoblMason County Environmental Health fee scheation at l for 24 h Date of Payment 4. Mason County Public must receive nolihcetion a[least 24 hours poor b the dolling of the well. PART 1:Applicant I Parcel Identification Site Address lyal & 7e[�nstr Rd Cbw.l-4vv Start Card# WE 555a& Drilling Fir Most-ke �loilI Phone So9-b90' lr�r71 Applicant it^ a GoyJV/S Y1 Phone Mailing Address 11011 L .Tfnvl city SkelAoyi State W_ zip Parcel Number 3a 1 30 1 5 Qn\ LoO �... Directions to Site J GrtSon R 'FO ck oh Is the well she within 100 feet of sait/seawater9 []Yes %No If yes,a variance from DOE is required. Have you applied/received(circle one)a variance? ❑Yes ❑No NorICE:Allproposed connedions ro new webs are subject to wateradequacy requirements at time of bulWing permit par Mason County ribe 6.68. Water usage restrct fists and additional fees mayapply to all new wells ddlled after January 19m.2018 per ESSB 6091, D4gma-9 Applicant/Agent Signature PART 2: Health Department Review(Staff Use Only) "1 YES NO i TAG# P -1 /� Called In s" I1 'j Fag z11 a 'Z1 ❑ Sr�,f Driller on Site? �yT LA -1 2 14 -�03 ❑ Is the well capped and Vented? r.� ❑ Is there evidence of a surface seal? Lo 0: _ t Z-S 1 Oy SJ yr 1 Is there a 2"annular space on all sides of the casing? El Has Has the seal slumped? n ❑ Is the well flowing or is there evidence of other leakage? f ❑ ,� 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? Pl ❑ 3 (�� t �1E �` wv y �=.1 ��� Pl � ItsseatneLTw Comments Vlp�ass ❑1F�ail, Inspector I f� t/ Imo' Date i,AJ YL, G4h1r� iS aN-�°beA a�o,.,n —4� c 3r. -MC cl is o:(- 1vu1 This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018 ewn"4 SvQ. � Ny� /� �b/�Aw �n /i �jJ� z . � �s :,` �' w 4lMun Py E WPM Oi _d a U' J d �, p^ ro Yeatllentl� y)£ V 3 ©O �, t (� n b �e n �0 O E ^ 0 E � s d m rn `� o � � r a a . o n 0 0 0 j t�ii O S O lNn d ^c. YtF J'-'T - • � ",4i ��+ �! t Gi " obi � Z � F .. a > > N Aly �yy�,''��'rF�a. y , q A .i �4 • f, t0 C n a Ln '1. 1 . •,t.� Y g i 4S • l\ ppA �( ' � Il ' t e _ b 1 {. * d ,!'� F`°; � `�► Jam . . �MRR 'iM,. C..u' �'rt ate! N � l T _ o Site Environmental 3 M > LAOFn � Map - DRAFT _ �. v $ 0 v ou - � = O O (p SN � oo0 o :5 N Parcel# 32130-75-00160 N ' g ::S 51. u �z XXX E Jenson Rd o 1 a N 3 L N ;S Shelton, WA 98584 3 9 to o p 0 N 6 A 'o r 1 � Wv 0 F LO 3 v C> 1<