HomeMy WebLinkAboutWEC2024-00124 - WEC Application - 11/12/2024 -,,, nn j 51 :6 STREET, SHELTON,WA 98584
.,,,„„,-.4, h=\, MASON COUNTY u, SH LTON: 360-427-9670, EXT.400
_ 0 LFAIR:360-275-4467, EXT.400
COMMUNITY SERVICES IL 1 2 ELMA:360-482-5269, EXT.400
\ i�/ &Idding.Planning.Environmental Health.Community Health NOVIV FAX:360-427-7787
NOTICE OF INTENT TO CONSTRUCT A WELL
Permit Number Payment Information Instructions
n 1. Complete Part 1. Incomplete applications will be rejected
WEC Receipt Number at1-4 3 2. Attach a plot plan and vicinity map.
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l._ 0 Cash 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.
t COL�� Date of Payment L1 l 4� 4. Mason County Public must receive notification at least 24 hours
prior to the drilling of the well.
' PART 1: Applicant/ Parcel IdentificationQ / / ' n Q
Site Address 'L 9 81 l� wl(,t SO✓, Lct kL 0 c 6 Start Card# I" E S 9 C32-S—
Drilling Firm 1 `(, t DYt (((�� Phone 3620 (— r 373—
Applicant S4-e,Vt. 6.ezi -G (\ Phone
' r1J i !,`"' SE
Mailing Address 1 2�1 -1 Z1 V �1
City 1 S CikOii J&& State 0/ QQ(S Zip al GI d Zi
Parcel Number 22 2 3- SSZ U C U 611
Directions to Site 4-'1_.=;;1?.."-:s..-s�Po.,„..7 "ru kQ Cr 1/14.en e`7 Lai kC OKr— �C! e/10
Is the well site within 100 feet of salt/seawater? ❑Yes [YNo
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 Mason County Title 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled after January 19'a,2018 per ESSB 6091.
Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG# Called In "1 t"ice F,44- Si . -1 1:5-
\4
❑ Driller on Site? o 1400.--S
Is the well capped and Vented? �1 •.� kA S
❑ El Is there evidence of a surface seal? L l ``� `1
❑ Is there a 2" annular space on all sides of the casing? 1`�
Has the seal slumped? ,\l'l
❑ Is the well flowing or is there evidence of other leakage?
❑ ® Is there evidence of cascading water?
❑ A Is there evidence that the seal is at least 18 feet long?
❑ rl Do the well site set-backs appear to be appropriate?
Comments 011 r), 10 i k-
❑ Pass ❑ Fail Inspector d Date
This form may be scanned and available for public view on the Mason County Web site. Revised:2/7/2018
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