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HomeMy WebLinkAboutWEC2018-00035 - WEC Application - 3/12/2018 �c•rr.,,� 0vs� �etc MASON COUNTY 1. 1) COMMUNITY SERVICES t,1y a,I. Building,Planning,Environmental Health,Community Health r4).ring'," 415 N 6'h Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 Belfair: (360) 275-4467 ext 400 •: Elma: (360) 482-5269 ext 400 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 41141 ,1AD 2. Attach a plot plan and vicinity map. (30 l D Cash 3. Submit this completed application with appropriate fee a Check minimum of 24 hours in advance of initiating well OC€) 5 f , construction. Refer to Mason County Environmental Health Date of Paymenk�j/ l l j X fee schedule for cost. II f 4. Mason County Public must receive notification at least 24 hours prior to the drilling of the well. PART 1: Applicant I Parcel Identification Site Address 1301 E Benson Lake Grapeview, WA Start Card# WE30715 Drilling Firm Arcadia Drilling Inc. Phone 360-426-3395 Applicant Joseph Builders NW LLC Mailing Address 2916 NW Bucklin Hill Road 162 City Silverdale State WA Zip 98383 Parcel Number 22104-75-90062 Directions to Site SEE ATTACHED MAP Is the well site within 100 feet of salt/seawater? ❑Yes Its Q If ye a nce from DOE is_required. Have you applied / received (circle one) a variance? ['Yes [ No A plicant/Agent Signature PART 2: Health Department Review (Staff Use Only) - YES NO TAG# D�k,-- i --6 Called In k/Z.f c1c _ ig ❑ Driller on Site? co c'{- tiJ 30•01% :{ "Z ❑ ❑ Is the well capped and Vented? gElIs there evidence of a surface seal? D N ❑ Is there a 2" annular space on all sides of the casing? ❑ LI Has the seal slumped? , ❑ ❑ Is the well flowing or is there evidence of other leakage? m Ej4 ❑ Is there evidence of cascading water? IZz ❑ Is there evidence that the seal is at least 18 feet long? (4=3 Niz ❑ Do the well site set-backs appear tot be appropriate? Comments t,o .(4 ,� (i,:,M� 1ti,,,� ;,.s , l IV i_ci H„d n n, kart,' c�,vtr, irsp.ir_l;cAn 'Pass ❑ Fail Inspector (Ayj.t� 6, -'J 1,t,,,L t� Date L{/3/?e,l Y; This form may be scanne"H an available for public view on the Mason County Web site. C:\Users\Connie.ARCADIADRILLING\Desktop\Drinking Water Notice of Intent to Construct a Well.docx Revised: 10/17/2017 . , . o .c, (.1 . . \ . . . § r ®util) 14 ' j w • . ]� {cc: \~\ ' _ . . E \ ! a a § �� 'cPc iz\t2i. (� ` G ' 1 ® §A§ p' : f a , 2\ § \t § ` , '. J 2 E ILI §\i&_ I| j /\/ k ig� � ^ i k § , _, tC = E` � m , itti'l .."\ I ! §°t / 2 E \i §§� qK §1 ./ k ! § e zEVE / g 8 k ' 2 & E ! z�� § § , vi s 0 • g9 EI \° § ` w B� B e £ § k § ■ $ §� § m m R. 8 � § §fi - 5 § % I e . kfn d e . a .% . q i g } \A@. § $ a ` § o £§ ? ( -g i o m CN \ CD . K q k 7 § -0 - § • icn § ) p. ) I o • • tto a ` '\ ` \ 2 0 +I I ® § 2 *6 = 1 f 11 8 0 /W 111.,-----qm MI cz, cq �1 II $''L-s� Hi 1,, i l �G'i•_W !L III r ' 3 U((' fill _ ° 1, 8 fi Ili !g4W 1 N{` I . / Z 2 O G s c a : o1.--tt:igt. --- YU \1G 8 "`KKKn � }�QS ; S � vw3 pp4Q� z y�� �y Q'w 41 qpW�8 §4 Mg 930 0 1 a.4 �W3pp t5+Y \ \W¢J 6�O�8n.Lvit '�I $ Ngigz •Q•1 0��X�Igg `$ Z rc z i.. s W ,'O Z, Oth\O a., fi s W Spp b `�',gam E G il F,W W '.' 0 s � 1 � .fyQoWQS/ li gl �W (8y `it ^ �!w 114 4 lib $ gg 01W ��N m n� W xi . . i ! i is 0 a ,,, il ig- 14s v Ia W Ff 1 r W E \ 8 O O. 0 \ a O o c $G f I o i 1 V P, a 1 N 7.1 N ,^ asz v "� N I N zal I Q O �]5 r N Mc'M, C O Cn 7 CT) a E U g m w o $� rn o L Na_ N 0 p N CO a C N ' 1 11,...,,.. �to � b r. G I y d -Is rlei 4,..30 ' , [RI s. It" • • . _ �� , 4 ( 1 € ,4 i,,.. ,>' II� ------------1. '- 4 - 4) --, . � N I ptrl r-j P; ! • , -J ...._ ,. c..,_ ,o ff $ �j�" f1-4 i,r 7. 'f 9cc) S- 4 j v N�8 0 '`n y a I`� C n / • 1 . \ ,..., , <------Z--- 1.• • r Hga_ • \, . • . / ,,,,,, --4: 4 p U ,it ` rF ! .� Z v1 v8i m° P -• "z'� t v) o gg d o ®� : t.? 1Q c� !') M U .w z Q • • iff . . • i t c 4.:::).— . I I ( 11.-. <I 4 C NJw . o