HomeMy WebLinkAboutWEC2024-00081 - WEC Application - 6/20/2024 MASON COUNTY n' —71K SH STREET,SH27-961 WA EXT.
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u� U SH67HELTON:360-427-96 r0, EM.400
COMMUNITY SERVICES JUN 2 0 2024 BELFAIR:360-2714437, EXT.400
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BY-----__ FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Pavment Information Instructions
Ynu,Oy�S 1. Complete Part 1. Incomplete applications will be miecled
WEC Receipt Number p1 2. Attach a plot plan and vicinity map.
❑ Cash 3. Submit this completed application with appropriate fee a minimum
'D Check of 24 hours in advance of initiating well consburlioc. Refer to
Mason County Environmental Health fee schedule for min.
Date of Payment b ^I 4. Mason County Public must receive notification ct least 24 hours
prior to the drilling of the well.
PART 1: Applicant I Parcel Identification ��` y
Site Address 14 � F_ _rAh`Jt4�, R[(,/ yY-;M rj Start Card#
Drilling Firm j�O\V I S `Jr I Phone � C
Applicant �Vht An1yt r'— Phone _
Mailing Address � �yC�1
City _� r7� State l/Vr1 Zip
Parcel Number 1-it-_q,.4,() — �.(��1—v(✓�(7 ��_y �
Directions to Site TaK2 9— LLt�I�^ � fY`w!1'ptFC.�1 ,
Is the well site within 100 feet of salt/seawater? ❑Yes �No
If yes, a variance from DOE is required. Have you applied received(circle one)a variance? ❑Yes 0141
NOTICE:All proposed connections M new wells are subject to water adequacy requirements at time ofbuilding permit per Masan Cu'rity TiOe 6,68.
Waterusage resldctbns and ad reel fees may apply to all new wells drilled aker Januaryp Ism,2018 par ES/Se6 1.
Applicant I lure � JPL� C�
PART 2: Health Department Review(Staff Use Only) V'7'•—
YES NO TAKE.-- all In
❑ ❑ Driller on Site? `
❑ ❑ Is the well capped and Vented? L4-T-
❑ ❑ Is there evidence of a surface seal? L046-
11 ❑ 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 cescading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long?
❑ ❑ Do the well site set-backs appear to be appropriate? y / ' ,/
Comments �.6 0.dllaKi�/I�lt- � uQ eAA arLli_
❑ Pass ❑ Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site. Rcvised:2/7/2018
Mason County WA GIS Web Map
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