HomeMy WebLinkAboutWEC2024-00087 - WEC Application - 7/16/2024 415 N 67H STREET,SHELTOK WA 985B4
MASON COUNTY SHELTON:360427 9670. EXT.400
COMMUNITY SERVICES BELFAIR:360-2754467. EXT.400
ELMA:360-482-5269,EXT.400
..+.....wx-sko . FAX:360427-7787
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NOTICE OF INTENT TO CONSTRUCT A WELL
Permk Number Payment Infonnalion Instructions
1. Complete Part 1.Incomplete
applications will be re;ectad I
WEC Receipt Number 2. Attach a plot plan and vicinity map.
(1A2 ❑ Cash 3. Submit this completed application with appropriate fee a minimum
ddUU Check of 24 hours in advance of initiating well constructor- Refer to
Mason County Environmental Health fee schedule for:osl.
Date of Payment Z111h1hA 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant l Parcel Identification
Site Address U,�J `-� "' �-" -' "l Start Card
f n n r1V \ Phone q(1Oo`Drilling Finn J f Ir\� "
Applicant IInA/i ff-- Phone
o
Mailing Address . in/ jF- S Fltt��¢
city 7 elfo l ✓ state ZIP _
LL 3 SU ISM {
Parcel Number 3 Oo� /� ' I2 �7� �p,��-
DirectionsloSite � LU—I'f,Y I`"I .10 NF �AMJ� � �� Wtl 11'L ' "'? -j<p
Is the well site within too feet of sell/seawater? ❑Yes ONO
If yes, a variance from DOE is required. Have you applied I received (circle one)a variance? ❑Yes [XNO
NOTICE:All proposed!connections to new wells are s.1i no water adequacy requirements at fine of building permit per Mason County The 6,68.. r
Wafer usage mornofons and adaddl^tbn�al fees mymatey apply to all new wells drilled afar January 19",2016 per ESSB 6091. i
Y/
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 AIA
❑ Pass ❑ Fail Inspector Date
This form may be scornetl and available for public view on the Mason County Web site. Revised:2/7/2018
Mason County WA GIS Web Map
1500 NE TAHUYA BLACKSMITH RC
1490 NE TAHUYA BLACKSMITH RD
1480 NE TAHUYA BLACKSMITH RD
ONE TAHUYA BLACKSMITH RD5'` a'
1430 NE TAHUYA BLACKSMITH RD
NE.LEAHY PL
51 NE LEAXY Pl.
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