HomeMy WebLinkAboutWEC2025-00057 - WEC Application - 7/30/2025 C�—� /\, F L—LyNCPS
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MASON COUNTY SHELTON:360-427-9670, EXT.400
I s "F . ) COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
i ✓— i ELMA:360-482-5269, EXT.400
y ,, ttl-er` yi/ Building,Planning.Environmental Health Community Health
\'�� FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
WEC Receipt NumbeX66-MS1. Complete Part 1. Incomplete applications will be rejected
2. Attach a plot plan and vicinity map.
.W ❑ Cash 3. Submit this completed application with appropriate fee a minimum
X)Check of 24 hours in advance of initiating well construction. Refer to
Mason County Environmental Health fee schedule for cost.
— Date of Payment_; s 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant I Parcel Identification /
Site Address i7c 67 y 1`, --5" Start Card# it-5g. c:r9 6,
Drilling Firm CeP044.-.a+ICE br .`j ) i 11, Phone? - -(9-QB
Applicant DeAA :1! ,Ijzp{n ES ,4 k Phone 3 ' -'Y 'L_7
75)
Address ,- /�DJe.
Mailing dd ess � t� r . � E�'oC
City6 -4-6 State if ,cA Zip 9
07
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Parcel Number 31 9 e .. ?/ " /1 eD 0 33
1 Directions to Site OILS o ,A •`,/!•;v-C iz
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? ElYes [ fo
NOTICE:All proposed con ctions to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
Water usage restrictions additional f ay apply to all new wells drilled after January 19'^, 2018 per ESSB 6091.
Applicant 1 Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In 1 I 2,9 12.S r.-a t Z
21-- ❑ Driller on Site?
❑ 0' Is the well capped and Vented? `j 1 le "(I ` 1 Z O l S`i
❑ Is there evidence of a surface seal?
2--- ❑ Is there a 2"annular space on all sides of the casing?
.E Has the seal slumped? riC3rnp--
ElIs the well or is there evidence of other leaks e? ►MY 0
❑ -� flowing g 5 2025
❑ Er Is there evidence of cascading water? , .:_.�
.2--- ❑ Is there evidence that the seal is at least 18 feet long? L 'f' ��- —
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❑ Do the well site set-backs appear to be appropriate?
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Pass ❑ Fail Inspector t1/1 jilt.- L t, 7 Date 7 5—
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:hiiis form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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