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HomeMy WebLinkAboutWEC2005-00005 - WEC Application - 1/10/2005 MASON COUNTY 15EPARTMENT OF HEALTH SERVICES SURFACE SEAL CONSTRUCTION PERMIT PO BOX 1666 SHEL rON,WA 98584 SHELTON (360)427-9670 RECEIVED FAX (360)427-7798 Receipt No. ELMA (360)482-5269 DateofPayment �I�o -(3� jA 1 o 2W5 BELFAIR (360)275-4467 TIDEMARK# W!_ LSO O 5 SEATTLE (206)464-6968 Instructions O o pp5" 426 W., CEDAR STI PART 1:Applica t(Parcel Identification Site House. � ,T ero.ec a 0 . suit card# 60' /6 2-/0 0rN1IngFIrmNam"r& ✓cf/ I e/( Ordtlan T <, Telephone# G L62-- Property Owner Name & T H-T'q • ( Telephone �� -67 -60 3G Melling Address 66y, of L{ j�-FC af7` r J4. R ifB Assessor's Parcel Number ��� 1 - 2 2. _ (� Subdivision(If applicabie) Div Blk_L41 oireal�s to sne r rrc� �v0 0/) TO� Is the well site within 100 feet of san/sea water? Yes_ No x— K yes,a variance from DOE is required. Have you applied/received(drde one)a variance?Yes_ o_ Applicant/Agent signature PART 2: Health Department Review(Staff Use Only) TAG# caned In Driller on site?............................i:�.............. ...............:............................... Is the well capped&vented?............................... ........................................:............................. .: ❑ ❑ Is there evidence of a surface seal? B 8 .............................................................................. Is there a 2"annular space on all sides of the casing? ..................................................... Hasthe seat slumped? ............................:................................:...:..................:.................. ❑ ❑ Is the well flowing or is there evidence of other leakage?.................................................• 8 8 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 Passed ❑ ❑ Inspector Date of Inspection . r � © Q ■ ( � e # � § } to & \ i - ? � - 0 - ^ ® ki7 , } \ ( j� ( fD ) 0 s - ) 7k = z/ C0 a\ k § !} ! (\ jo t m K= k \ ± m 3 � M 2 & t a % § 0 CD CD f 0 CD � E ` - - ` \ ) K E | o ! # „ , . ■ g � } $ �