HomeMy WebLinkAboutWEC2025-00021 - WEC Application - 5/13/2025 &iZMQrYI CIA i DPP bstrtE ) ,aa.It4A
<oS° tit'.'\ 415 N 6T"STREET, SHELTON,WA 98584
0,,,, MASON COUNTY SHELTON:360-427-9670, EXT.400
'I ' ' COMMUNITY SERVICES BELFAIR:360-275-4467, EXT.400
% ELMA:360-482-5269, EXT.400
..,,% Building,Manning 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 ZOZ5 - 2. Attach a plot plan and vicinity map.
ZOZ 6- ❑ Cash ooa L/3 1 3. Submit this completed application with appropriate fee a minimum
'M Check of 24 hours in advance of initiating well construction. Refer to
00i.I Mason County Environmental Health fee schedule for cost.
V Date of Payment OZ-20- 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 e t%i t/t et..c, I,/
r. Start Card# 0-/E. .37
Drilling Firm , -A\Ai Dvtr( ( , r Phone 2 7S-ST3 Co—)
Applicant c HO) S Phone
Mailing Address pd f' ''
City &/,rA re VI W VOrt k State VV 14 Zip 7 (c
Parcel Number 121 05— 3 / L LI U Z a
Directions to Site picrciSS Cin'L_. 4/6Y 2G Ci v-cc t v t� ( �� qaffv.),1-e_.
1 Ma-4-N
Is the well site within 100 feet of salt/seawater? ❑Yes Jo
If yes, a variance from DOE is required. Have you applied / received (circle one) a variance? ❑Yesr-rNo
NOTICE:All proposed connections to new wells are subject to water adequacy requirements at time of building permit per Mason County Title 6.68.
Water usage rreestriicctiioons and additional fees may apply to all new wells drilled after January 19`h, 2018 per ESSB 6091. �y�
V Appli nt/Agent Signature 8MUMIC v
PART 2: Health Department Review (Staff Use Only) M FEB 2 0 2025
YES NO TAG # L41\ Called In
❑ .❑' Driller on Site? L{IIL4kL Fog I* ItS12.S
D--- ❑ Is the well capped and Vented? Niooi'i
Er ❑ Is there evidence of a surface seal?
.,Et" ❑ Is there a 2" annular space on all sides of the casing? u "� 5 (pc)(pc)
❑ � Has the seal slumped? 0 3-t
❑ j2" Is the well flowing or is there evidence of other leakage? t Z 2 - g '
❑ Is there evidence of cascading water?
❑ ❑ Is there evidence that the seal is at least 18 feet long? 1cc oaS V-
❑ Do the well site set-backs appear to be appropriate? I
Comments / -i.cti 1 , �S�CCL u- 1 e o 4"0 i2. /2 0 p t 1 L/ SS al eze'1(tr (}N��
Pass ❑ Fail Inspector i Date < t ;I Z1
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
Iliii""Ff'--.• ''' ' . Mason County WA GIS Web Map
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Tax Parcels (Zoom in to 1:30,000) Source:Esn.Maxar,Earthstar Geographies,and the GIS User Community
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Mason County WA GIS Web Map Application
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