HomeMy WebLinkAboutWEC2025-00016 - WEC Application - 1/9/2025 oFf St•i-CL-rscl•MA't t.oc R.D
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415 N 6TH STREET, SHELTON,WA 98584
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MASON COUNTY SHELTON:360-427-9670, EXT. 400
l 'I I' COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT. 400
,J - 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 Instructions
1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number if ZC.ZS 2. Attach a plot plan and vicinity map.
2025 ❑ Cash ` pve62 3. Submit this completed application with appropriate fee a minimum
0 Check of 24 hours in advance of initiating well construction. Refer to
ooO I (n C () Mason County Environmental Health fee schedule for cost.
`lam Date of Payment �Z'��' 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
PART 1: Applicant/ Parcel Identification
Site Address 32(( ltij i_iN-le ew-. IZ ( " SLe..H-zr.. Start Card# \/•. f-5 q 9 g
Drilling Firm ki✓/ 'S AjQ yi /jlJ J(S Phone 3(00 -73�- 7093
Applicant i/)Jc(,L' F/vr2S Phone .1/06. -3F/-OS72
Mailing Address 32// GI) L /c 6-9 pf El
City �'kL/-avt State jriJ/ Zip 9g58e/
Parcel Number D ZO 2/t( 30aoo
Directions to Site op-on f.41-&t 's)-, Xa-cf><sn//rlu/t4ci_ ol, Li/-117< L cm7< 1�l /�F/
Is the well site within 100 feet of salt/seawater? ❑Yes ONo
If yes, a variance from DOE is required. Have you applied/received (circle one) a variance? ['Yes ❑No
NOTICE All proposed connections to new wells are subject to water adequacy requirements at time of building permit per Egim.wEWater usag restriction,and adddi I fees nay apply to all new wells dolled after January 19m, 2018 per ESSB 6091.
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Applicant Agent Signature
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PART 2: Health Department Review (Staff Use Only) By
YES NO TAG# 7d) L. O?2_ Called In 4!I f(t'S tw 4 I I4-12
❑ Z Driller on Site?
12/ ❑ Is the well capped and Vented?
❑ Is there evidence of a surface seal? Z°3 DGIb
rE ❑ Is there a 2" annular space on all sides of the casing? Z • Z Sa d
❑ Has the seal slumped? ) Z3 .
L] Er Is the well flowing or is there evidence of other leakage?
ElL Is there evidence of cascading water?
p h(.o ❑ 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 4 10 ZS'
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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