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HomeMy WebLinkAboutWEC2008-00067 - WEC Application - 5/8/2008 r MASON COUNTY / DEPARTMENT OF HEALTH SERVICES V "Always Working For a Safer, Healthier Mason County" 426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584 SHELTON (360)427-9670 ELMA(360)482-5269 BELFAIR (360)275-4467 WEBhftp,//www.co.mason.wa.us FAX(360)427-7798 APPLICATION FOR WELL SURFACE SEAL CONSTRUCTION PERMIT C E f �� �_ Ftla mber: SS'ZovB — �7 WEC: MAY 0 S Z008 Pan/1, incomplete applications will not be accepted lot 4n and vicinity map r n/I r 0NME^' I"AIis completed application with appropriate fee(s)a minimum of 24 hours in T advance if initiating well construction Date Received 4 The Mason County Health Dept. Must receive notification at least 24 hours prior to the drilling of the well PART 1: Applicant 1 Parcel Identification Site Address 340 E. Willow Blue Lane Shelton, WA 98584 Start Card# WE08329 Drilling Firm Arcadia Drilling Inc Phone 360-426-3395 Applicant Jack& Eleanor Mitchell Phone 253-531-3880 Mailing Address 9012 S. Thompson Avenue City Tacoma State WA Zip 98444-4350 Parcel Number 321367500020 From Shelton, travel north on Hwy 3 and turn left on Lavender Ln. Follow as road turns into Willow Blue and Direction to Site look for site at address and Arcadia Drilling sign on right. Is the well site within 100 feet of salt/seawater? ❑Yes ©No If yes, a variance from DOE is required. Have you applied / received (check one) a variance? ❑Yes ❑No Connie Williams(for)Arcadia Drilling Inc Applicant/Agent Signature PART 2: Health Department Review(Staff Use Only) YES NO TAG# Called In CCU ❑ ❑ Driller On Site? ❑ ❑ Is the well capped and vented? ❑ ❑ Is there evidence of a surface seal? ❑ ❑ Is there a 2"annular space on all sides of the casing? ❑ ❑ Has the seal Slumped? ❑ ❑ Is the well flowing or is there evidence of other leakage? ❑ ❑ Is there evidence of cascading water? ❑ ❑ Is there evidence that the seat is at least 18 feet long? ❑ ❑ Do the well site set-backs appear to be appropriate? Comments Pass Fail Inspector Date r ©o me cn ao a � 9 is n ^ d if a n S � D c xw — 1 ... o d ,V 3:=- O CD � J =T n o F o CD rn E CD T 0 3 N J aam N w l` n a p� , - n n Y a6 y