HomeMy WebLinkAboutWEC94-0048 TPN42001-44-00010 - WEC Application - 10/18/1994 MASON COUNTY DE ARTMENT OF HEALTH SERVICES
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�` QO1III�6'ct aap�1 WELL CONSTRUCTION PERMIT I F( �
1� n Receipt No: .0 UUUIIl...111
Date of Payment: OCT 18
INSTRUCTIONS ❑`I
j 1. Complete Port One. LTFi SE1 7 Y K
2. Pay t6o fee and submit this application a minimum of 24 hours in advance of initiating cone ructlen. Make cheek
payable to: Mason County Treasurer
A. Attach plot Plan.
4. 24 hours prior to drilling the well, contact the health deportment and prodide start card njiber tolntg am of the
Ii( following methods. Fes to' 427-7798, or telephone: 627-9670 est. (8:00(I a..PART I: APPLICANT/PARCEL IDENTIFICATION �l/1. !G 4l J C) �
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SITE HOUSE ADDRESS Island Lake Rd .
DRILLING FIRM NAME Arrnrlin Drilling Inc START CARD No. WO55981
PROPERTY OWNER'NAME David C . Bayley TELEPHONE 206 426-.9713
MAILING ADDRESS PO Box 278 Shelton, WA 98584 %'
:1_ y 1 9000
ASSESSOR'S PARCEL NUMBER 4 2 0 0 1 _ 4 4
SUBDIVISION (If Applicable) DIV ]ILK LOT _
DIRECTIONS FOR LOCATINO SITE N R— W
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DATE OF ANTICIPATED INITIATION OF WORK! 10-21 -94
+ " DATE OF ANTICIPATED COMPLETION OF WORK: 10-2.1 -94
PART 2: DEPARTMENTAL USE ONLY
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TIDEMARK NO.
CALL-IN DATE CALL-IN TIMB
START DATE START TIMB AMIPM
COMPLETION DATE COMPLETION TIME WPM
TAOOINO AND SEALING SATISFACTORY? yes ONO
COMMENT
INSPECTOR DATE OF INSP CTION
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