HomeMy WebLinkAboutWEC96-0170 - WEC Application - 7/9/1996 - RECE1VEL
' an JUL 81996 `
MASON COUNTY DEPARTMENT OF HEALTH SERVICES 'C'Al TH SERVic«
POST OFFICE BOX 1666
SHELTON, WA 98584
(360) 427-9670
WELL CONSTRUCTION PERMIT FAX 42 7-7798
Receipt No: ✓
Date of Payment:
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INSTRUCTIONS
1. Complete Part One.
2. Pay $40 fee and submit this application a minimum of 24 hours in advance of initiating construction. Make check
payable to: Mason County Treasurer
3. Attach plot plan.
4. 24 hours prior to drilling the well, contact the health department to give notificatio of starting. Fax to: 427-
7798, or Telephone: 427-9670 ext. 358 (8:00 a.m.-5:00 p.m.)
PART 1: APPLICANT/PARCEL IDENTIFICATION (lam —�
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SITE HOUSE ADDRESS ,k to L�� A �t ,.,II f� /J-..>tf
DRILLING FIRM NAME fJ G C- (^ , l I l Cl.-t! START CARD Mo.
PROPERTY OWNER NAME Qc\QQQ(N qh Jj o( Qe (�Ctt P�v p - 4TELEPHONE jo
MAILING ADDRESS .0 u o 1 1 S
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1 y S aaEe zip
ASSESSOR'S PARCEL NUMBER \`—
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SUBDIVISION (If Applicable) DIV _ ELK LOT
DIRECTIONS FOR LOCATING SITE N.k" G00 '-T A_ (.t yA "� i-A/' lecl
ATTACH PLOT PLAN
DATE OF ANTICIPATED INITIATION OF WORK: � 4
DATE OF ANTICIPATED COMPLETION OF WORK:
PART 2: DEPARTMENTAL USE ONLY
TIDEMARK NO.
CALL-IN DATE 24 CALL-IN TIME AM/ply
START DATE START TIME AM/PM
COMPLETION DATE COMPLETION TIME AM/ply
TAGGING AND SEALING SATISFACTORY? U Yes U No
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INSP CTO DATE SPECTION
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REVISED 01/07/96
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