HomeMy WebLinkAboutWEC95-0037 - WEC Application - 2/24/1995 � y
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MAIN COUP DEPARTME ,TT OF HEALTH SERVICES
POST OFFIC E I3OX 1666
SHELTON, WA 98588
(f) (20 ) 427-9670
rn r F X 427-7798
APPLICATIW FOR WELL CONSTRUCTION
M -. 5
kceipt No:
Date c Payment:
INSTRUCTIONS
1. Complete Part One.
2. Pay $60 fee and submit this application minimum of 24 hours in advance of initiating construction
3. 24 hours prior to drilling the well, cc .!ct the health department and provide start card number s rig one of
the following methods:
Fax the notification to 427-779 or Telephone the calt-in tine:
PART 1: APPLICANT/PARCEL IDEP TIFICATION
wECIS..... �3. ..
DRILLING FIRM NAME _'b
'�S��--��_... ?W g_ -4-- START CARD NO. U
PROPERTY OWNER NAME �ft�.�, 4V�A �` TELEPHONE p O 5— /
SITE HOUSE ADDRESS fr37�0_ PINE
MAILING ADDRESS _
Iy a e ip
ASSESSOR'S PARCEL NUMBER 2"
SUBDIVISION (If Applicable)_ _ DIV BLK LOT _
DIRECTIONS FOR LOCATING SITE
DATE OF ANTICIPATED INITIATION OF 'iORK:
DATE OF ANTICIPATED COMPLETION OF :TORK:
PART 2: DEPARTMENTAL USE ON,
TIDEMARK NO. _
CALL-IN DATE CALL-IN TIME AM Pr,1
START DATE ,. START TIME AM PM
COMPLETION DATE _ COMPLETION TIME AM PM
n
TAGGING AND S�(ALING SAT�I ,FACTORY? EjYes U No
COMMENT /'T�CT
INSPECTION
INSPECTOR
��- DATE O