HomeMy WebLinkAboutWEC2001-00106 - WEC Application - 10/8/2001 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
SURFACE SEAL CONSTRUCTION PERMITPO BOX 1666 SHELTON, WA 98584
LOCAL(360)427-9670
BELFAIR(360)2754467
Receipt No. FAX(360)427-7798
Date of Payment
TIDEMARK#lQ C.ZQI—Pn I D
Instructions
1. Gompie s.pact os e
fee ands..Wit this.a]Me on a minimum of 2�t hours rn adsiance of rnfiatin�construction.
Male ch k is yabl+ #�z MASON COUNT MEASIIR I+
3. 24 hours pnaft�d6I1Jn�the w..1: .06tactth�heath�fepaI tote At pure no atfah Of garb
Fax to( ti)dfi T798;gr Tel Extenssan61
4 Argon plot plea.:
PART 1: Applicant/Parcel Identification
Site House Address 2 9 6 J Fie- Wcgo e,— Q!� Start Card#
Drilling Firm Name /V oY4�-t We-j Telephone#
Property Owner Name Telephone#
Mailing Address
Assessor's Parcel Number 6 `2, 2 L, - 3 3 - a n U
Subdivision(If applicable) Div Blk Lot
Directions To Site
Mcj i oc-k. or--A46 f;rsf ( F} i�nS+ Cv c� . A��ao .
'b w•.'res 4.0 96f
PART 2: Heath Department Review (Staff UseOnly)
Lorrc-aQl Ppr tee1t Fromm-, 13 V1 Luc—
TAG# QJ I OA10 YES NO
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Driller on site? ❑/
Isthe well capped &vented?................................................................................................ V" ❑
Is there evidence of a surface seal? ................................................................................... �J ❑
Is there a 2"annular space on all sides of the casing? .....................................................
Hasthe seal slumped? ......................................... .................................................... ❑
Is the well flowing or is there evidence of other leakage?.................................................. ElQ
Is there evidence of cascading water? ...............................................................................
Is there evidence that the seal is at least 18 feet long? .................................................... ❑
Do the well site set-backs appear to be appropriate? ....................................................... ❑
Comments P-,�%QCA l O Cb` Called in
Inspector Date of Inspection