HomeMy WebLinkAboutWEC2006-00321 - WEC Application - 11/3/2006 MASON COUNTY
DEPARTMENT OF HEALTH SERVICESI
426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584
SHELTON (360)427-9670 ELMA (360)482-5269 BELFAIR (360)275-4467
WEB http//www.co.mason.wa.us FAX (360)427-7798
APPLICATION FOR WELL SURFACE SEAL CONSTRUCTION PERMIT
f. Receipt Number: S5-2-vr o Z l 'i WEC:
1. Complete Part 1, incomplete applications will not be accepted
2. Attach a plot plan and vicinity map
3. Submit this completed application with appropriate fee(s) a minimum of 24 hours
LTH SE�, in advance of initiating well construction.
(CFS ` 4. The Mason County Health Dept. mus
Date Received t receive notification at least 24 hours prior to
the drilling uf the well
PART 1: Applicant/Parcel Identification
R%
Site Address 4tar/`Card# '(J . S I Z�
Drilling Firm -` Phoneme—Z7� '-7l 3�
�4eNj'}�U Phone 3� _-5 7— 5'335-
Applicant T� /�fe
Mailing Address A\IL�_
City ��te Q� State L,J11�? Zip
Parcel Number
Directions to Site Rdn ' i:d IR ETA bb II i A 'Pn '*&Pu l �y �f k Z2
1 M
I)r�u�lF 1 ew ci �J vn i (c7 laD�S O.y L' 29-
Is the well site within 100 feet of salt/seawater? ❑Yes�No
If yes, a v rian from DOE is required. Have you applied/ received (circle one)a variance? [-]Yes ❑No
I- \
v Applicant/Agent Signature
PART 2: Health Department Review(Staff Use Only)
YES NO TAG # Called In
❑ ❑ Driller on Site?
Is the well capped and Vented?11 El Is there evidence of a surface seal?
El ❑ Is there a 2" annular space on all sides of the casing?
Has the seal Slumped?
°❑ °❑ Is the well flowing or is there evidence of other leakage?
Is there evidence of cascading water?
11 ❑ Is there evidence that the seal is at least 18 feet long?
❑ ❑ Do the well site set-backs appear to be appropriate?
Comments
Pass Fail Inspector Date