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Home My WebLink AboutWEC99-0023 - WEC Application - 2/16/1999 Mason County Department of Health Services _ Yost T We SURFACE SEAL CONS UNION PERMIT Shel n, WA 98984.' Am�p�: ( OI 427-9670 " Receipt Number: �I98 Permit Number: 3 kl. Instructions: FFB 16 ?g; _:•�:.,.......�.::::..:........_;......< ..,.._.......:....>»,,,era,:<.;:<.::<:,:,::;av <'.>-;�.�,. .r..�,�.>x:<:,�:<..:�'� ;:;:... ;rho �>s;; n ry:G..<.✓ � �•::fi:': ,v�?<,n bi.Y.;:c`.yy rim;:_H�r.;.;..;. ::x.:: •.��,. ..>.f?!::.:<s is;s'«.'.{<s.� :3;�wik�.:.s: . ..:�:.:m`..:...,,-:>Y. s _.,�'"• .�..;.x c::s>rr�: �.:8..�. .._v.:;.:,.: r`'s'"�>�''�,�.,�!.9.+< �:�"�rs.:X,�;s'"��9r,<.sF a°xr ✓,�'.F Ks„✓�`"+�; s.k�.n xN . t> <f. � - (�.�'(1�/ Y � > } w .< •a ..y � c:}^T.. :<f< .,. :�` >:ii"V`:..tr.' I�':?N,'^ )^�Q> BRY,:..�<l v.'�'>,;�•.w'_J•�P�.�YGE>. .:i%3":r ^:y.�',>i:Ts:.@a...::�<s:• -< F&.:�..y.w^::::tva::,.b .xW "''4'x.'�.'..k.,.u*..e?::a ...fib.. �.:,n,..,4.,. yo:.+:. ,.:.y.:r,; >,:2#.r ::fib' •r�3Z<;:<ssn<.. <2'!F£': -:y<u PART 1: Applicant/ParcelIdentifiic_ation �HL' Site House Address: Igo Nd' ffkaprN Lk D"�sW card#: La 296 DtillingFirmName: b(ZiLU lq6-_— Telephone#: 360=2 Owner's Name: (— 1 LL�— kCIS/N46aTelephone 2�9 7 MailingAddress: 9a Assessor's Parcel Number: ��' —D O � q`7 rbdivision(If applicable): Div Blk_ t Directions To Site: PART 2: :. Heath Department Review(Staff Use Only) TAG# i I q 2(oDate Called In: . NO Driller on site? ....�...... ........................................ ... . Is the well capped&verttedT .....'..........................................I...... ...... '� ❑ Is there evidence of a surface seal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . in ❑ Is there a continuous seal surrounding casing? : . . . . . . . . . I . . . . . . . . . . . . . . . .. ❑ Has the seal slumped?.....'............................................................. ❑ Rd Is the well flowing or is there evidence of other leakage? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Is there evidence of cascading water? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ : 6� Is there evidence that the seal is at least 18 feet long?. ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .)a ❑ Do the well site set-backs appear to be appropriate? . . . . . . . . . . . . . . . . . . . . . ❑ PART 3: Conclusions Inspector Comments: �9 Well Construction Satisfactory ❑ Well Construction Unsatisfactory - axl Signadue Date _I'1 4 J:� Par W1WPOATA% .WPD � WL