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
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