HomeMy WebLinkAboutWEC2016-00031 EXPIRED CLOSED - WEC Application - 4/26/2016 otv coUN
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Public 4, Health
Always working for a safer i•healthier Mason County CI
415 N 6th Street, Bldg 8, Shelton WA 98584, ll
Shelton: (360)427-9670 ext 400 + Belfair: (360) 275-4467 ext 400 + Elma: (360)482-5269 ext 400
FAX (360)427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number }2 0( k"` 2. Attach a plot plan and vicinity map.
❑ Cash 3. Submit this completed application with appropriate fee a
0 Check minimum of 24 hours in advance of initiating well
construction. Refer to Mason County Environmental Health
(j0(22 Date of Payment ` -bit (D fee schedule for cost.
4. Mason County Public must receive notification at least 24
hours prior to the drilling of the well.
PART 1: Applicant/ Parcel Identification (quo Site Address KKK 0 LSO -E�-� t r-rw Start Card#
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Drilling Firm v SL t ( Phone
Applicant toodcyl Phone 5CO277 /q7 7
Mailing Address
City Jl4,--erdee State (-Pc( Zip ffi 3
Parcel Number 0 ( 00 09 6
Directions to Site r (dddl1 (=.((--‘ce(r ( 14 L j
Is the well site within 100 feet of salt/seawater? Eyes o
If yes, a riance f m OE is required. Have you applied/ received (circle one) a variance? ❑Yes ❑No
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
❑ Pass ❑ Fail Inspector Date
This form may be scanned and available for public view on the Mason County Web site.
J:\EH Forms\DRINKING WATER FORMS\Drinking Water Notice of Intent to Construct a Well.docx Revised: 12/1/2015