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HomeMy WebLinkAboutwec2025-00058 - WEC Application - 4/14/2025,fir' irc I r • . 7 MASON COUNTY 415 N SHEL ONE 360-427-9670 EXT.4 0 ■ COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400 ELMA:360-482-5269, EXT.400 Building,Planning,Environmental Health,Community Health FAX: 360-427-7787 NOTICE OF INTENT TO CONSTRUCT A WELL (Permit Number Payment Information I� Instructions Complete Part 1. Incomplete applications will be rejected WEC Receipt Numbe Attach a plot plan and vicinity map. 020 -ebb 0 Cash)22 3. Submit this completed application with appropriate 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 4. Mason County Public must receive notification at least 24 hours 451.at prior to the drilling of the well. PART 1: Applicant/Parcel Identification / Site Address �lib�! 2 /1/ ..�c Start Card# / cr16 - G J Drilling Firm CaZof LvCCGl� �r►` i I }ytq Phonea9-g3 `2� Applicant -it$Ap �/ L- 44 1 Phone S 70 -3Z9 Mailing Address 6 F, / cf'1?4d h J_h-,-e DJ". City L ."7 OA, State tr..." - Zip 9 S'Cr g.a Parcel Number ) ! &... tt? cQB 2 ] Directions to Site c9+ �A •`/) � /Z I ' , Is the well site within 100 feet of salt/seawater? ❑Yes 2 1 If yes, a variance from DOE is required. Have you applied/received (circle one) a variance? ❑Yes EtITOr NOTICE:All proposed c.••ections to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68. Water usage restricts•a:•. additio I fees may apply to all new wells drilled after January 19`",2018 per ESSB 6091. Applicant/Agent Signature PART 2: Health Department Review(Staff Use Only) YES NO TAG# Called In „e ❑ Driller on Site? ❑ .2 Is the well capped and Vented? �� J ❑ Is there evidence of a surface seal? ❑ Is there a 2" annular space on all sides of the casing? MAY 5 2025 ❑ ❑ Has the seal slumped? 13 a i , ---t ❑ �� Is the well flowing or is there evidence of other leakage? BY ❑ .❑ Is there evidence of cascading water? i-�6-'c- vy�e-rJL-A ,� CI Is there evidence that the seal is at least 18 feet long? 4 1 IQ at -2-et 1 ❑ Do the well site set-backs appear to be appropriate? y-2) c,,-1 ( --.`( r Comments S I) >T y t- /Kass ❑ Fail Inspector z 7 Date k/ aS' `?--4-- 4.d1C I This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018 ,ti I"Y 1 l S e-f Z- C i- 4 -t 2`, t _ `Y • , 1 . • .. _tz „ , L � - i Z0� 1i / ...i! Q(coP. ! DQivEty)AAA 1 P S°:X Qd f , f" .th-A *---- "•(1. l', 73 \ \ ,,i i t.,,,. . © 'min :n ', ofecit)( k r i SL I i • ZA C9 5‘ :. - . 4" I--:-2, \ 11 3 _ 4) ; U P 1 3�� SLopg ! i t ofosGD Toc 10a 'ram w5G L R2- fRt2N� 5HARofl it-N 34,1D2--r5-Ra2o _v,,. r rev: \)i 0 so A4 coor J a ALA pL ;. x \...1 C , n rl�tct�GTt-i Ft�Js /� _„0 GallonPre-Trashtank # 0 G i5' �L �J -B\R-50G ?�TIJ Tank �?Zvate_ 01 g- tO s—C�t u et- n 000 Gallon Pump Chamber '��' ' - v Valve Control Box 2 x�G am P` ,r , v\ .�-- 4^ r' }?. 3 2:i ( L� .i -�—?L.L. t ,,: iy� \rZS .`C`ei l irl l+,�Q,kw-ek;`, ~'2 OLD C !f1�ctLG^,A'- t ti ftOL� IF X`, i" •' i."R Arrow Septic Designs 171 E. Vuecrest Dr 1 Union. WA 98592 (360)898-2255 APR 1 4 2025