HomeMy WebLinkAboutWEC2000-00190 - WEC Application - 9/27/2000 V
. ° vIASON COUNTY
I
DEPARTMENT OF HEALTH SERVICES
FAA
SURFACE-SEAL CONS TOx,WA 98594
ry 060)427-9670
itxeipt No. � 5 � / B ( 275 4467
DateofF ct F (360)427-7W8
TIDEMARK#
Instructions HEALTH SERVICES
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PART 1: Applicant/Parcel Identification U �p
Site House Address ��,i i�P T� -��1 art Card#
Drilling *N) S �IZtuu Al /r Telephone#
Firm Name 1 7
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Property Owner Name -9 A04 jTOnlers Telephone# 29—
Ma1Nng Address -
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Assessor's Parcel Number z'--
Sub ion(If apolki bk l Div_Blk L Dt_
Direcdons To Site
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Is the well site wfthin 100 feet of sell/$"water? yes— No ,(1�
If yes,a variance from DOE is required. Haws you appfiedlreceived(akc�1Pne)a wulance?Yes No
1 ppploptWAgent Signature
'PART 2: Health Department Review (Staff Us#Only)
TAG# YES NO
jDriller on site?...................................................................................................................... ❑ ❑
iIs the well capped&vented?................................................................................................ ❑ ❑
is there evidence of a sWkm seal7 ................................................................................... ❑
Is there a 2"annular space on all sides of the casing?..................................................... ❑
Hasthe seal slumped? ..... .............................................................. - .................. ❑ ❑
Is the wall flowing or is there evidence of other leakage?.................................................. ❑ ❑:
s there evidence of cascading water? .................. ..... ... ...............I................... ❑
is there evidence that the seal is at least 18 feet long? ........ .......... . ................. ❑ ❑
j Do the well site set-Incks appear to:be appropriate? ....................................................... ❑ ❑
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