HomeMy WebLinkAboutWEC2009-00009 - WEC Application - 2/9/2009 h„• MASON COUNTY
PUBLIC HEALTH .
"Always Working For a Safer, Healthier Mason County" _��
426 W CEDAR ST, PO BOX 1666, SHELTON WA 98504
SHELTON (DEB)http'////6www co.masonwa.us FAX (3 0)27-8 )275-4467
442
NOTICE OF INTENT TO CONSTRUCT A WELL
E Ci E I V E� Receipt Number: WEC: 9- 9
FEB 0 9 2009 1. Complete Part 1, Fee$77.00 incomplete applications will be rejected
2. Attach a plot plan and vicinity map
ENV' - 3. Submit this completed application with appropriate feels)$75.00 a minimum of 24
L4�te"A"A ved hours in advance of Initiating well construction.
4. The Mason County Health Dept. must receive notification at least 24 hours prior to
the drillingof the well
PART 1: Applicant 1 Parcel Identification M
Site Address Start Card#
Drilling Firm Phone L� • ��Q�
Applicant 1�rt��� (1n, it Phone
Mailing Address V) SX 10�a�
City IPA" 1'(� ^ _ State 11d.� Zip
Parcel Number
Directions to Site
Is the well site within 100 feet of salt I seawater? []YesWe
If yes, a variance from DOE is required. Have you applied lI received (circle one)a variance? []Yes ❑No
,. Applic t/Agent Signature t
PART 2: Health Department Review (Staff Use Only)
YES NO TAG# �5-6L D Z Called In
❑ .J�t' Driller on Site? �`/_SIL+�✓I
❑❑ Is the well capped and Vented?rr !C
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 sittes set-backs ap�ear o be approplriate?
Comments A to Q'7 r re
Pass Fai Inspector Date �mld9
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