HomeMy WebLinkAboutWEC2025-00019 - WEC Application - 2/18/2025 aFF
FEB 18 25 f111 / 3R 10(.
MASON COUNTY By 115N6Ta STREET,SHELTON,WA98594
Go COMMUNITY SERVIC S BELFAIR:360-275-4467,EXT.400
ELMA:360482.5289,Ek .400
FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
r P It Nu bar Pa ant info an Inaete applications
1. Coach a Pan 1.Incomplete applications will be rejected
WEC Receipt Number "5 � 2. Attache plot plan and vicinity map.
,ZO25 ❑ Cash -CEEV37 3. Submit his completed application with approprate fee a minimum
❑ Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
Date of Payment Z� ' 4. Mason County Public must receive notification at least hours
prior to the drilling of the well.
PART I Appllc /Parcel Identification
tC-QCcw A fstan Card#
Drilling Firm lAQ vs '(�` Phone Z C";)sa l-Q 107 P5
Applicant ^ � 5 Phone
Mailing Address�3y�y 'J (�
^City 0f7-C- rr State w Pc- 7Jp a`6Cj�i
Parcel Number
1-\wy JO(s Ito St
Directionsto SiteE — t
Isthe/ iJa311_to within iDO fee[�satt/seawa seawater? W❑No� �� ��t�
es
If yes, a variancefrom DOE is required. Have you tip ied/received(Circle one) v dance?? ❑Yeas-❑No
NOTICE:Allpmposedconrwc8pnsfomwwallsamsub,kc lOwaferade wcymquiwfseftlmeo/buddtl gpermlfpsr Meson Coon 1We6."..
Waferu ge reafrrcAionseMaddiGanel lesemy apply fOaftwwOsdiedaerJanua f9'",2a18 N\ ry per E5868091.
C� is
Applicant Aont Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In IQIZs
❑ ❑ Driller on Site? /
❑ ❑ Is the well capped and Vented? �.-��2/ 1g
❑ ❑ Is there evidence of a surface seal? ---
❑ ❑ Is there a 2"annular space on all sides of the casing? �{
❑ ❑ Has the seal slumped? r�1 y r•yoliSZ- J
❑ ❑ Is the well flowing or is there evidence of other leakage? _ '
❑ El Is there evidence Of cascading water? VV
❑ ❑ Is there evidence that the seal is at least 18 feet long?
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments
❑Pass ❑Fail Inspector I'7 Date
This form may be scanned and available for public view on the Mason County Web site. Rcvised:2/7/2018
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