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Home My WebLink AboutWEC2001-00171 - WEC Application - 1/20/2001 MASON COUNTY 7EPARTMENT OF HEALTH SERVICES SURFACE SEAL CONSTRUCTION PERMITYO BOX 1666SE BLTON,WA 98534 LD AL(360)427-9670 BBU rAIR(360)2754467 Receipt No. FAX(360)427-7798 Dvk Of TIDEMARK## t 6 Instructions Xzz6t7) PART 1 Applicant/Parcel Identification VICES (Site House Mddresne\��i tr ffw - 1JI)I S 1.Q A21 PStart Card Drilling Finn'',Namei V CZ2jt�'ST ( D'',Il:04 noc- Telephone# Z Property Owner Name IpNdCL1 =n) '6L(L4/ Telephone# Melling Address Lf;'L�� QPz.S i :� ti1y*t,3ff=&q Assessor's Parcel Number Z ��- 7 1Z 0 Subdivision(If applicable) Div_Bik_ xt Directions Tb Site PART 2; Health Department Review (Staff UseOnly) TAG# /7 r T N A r YES NO Driller on site?...................................................................................................................... ❑ ewe Isthe well capped&vented?................................................................................................ ❑ Is there evidence of a surface seal? ................................................................................... ❑ Is there a 2"annular space on all sides of the casing? ..................................................... Hallthe seal slumped? ....................................................................................................... ❑ Is the well flowing or Is there evidence of other leakage?.................................................. ❑ Is there evidence of cascading water?............................................................................... ❑ Is there evidence that the seal Is at least 18 feet long?.................................................... //'' ❑ Do the well stie set-backs appear to be appropriate?....................................................... ❑ Pass...................................................................................................................................... ❑ Com rlts . w, Called in `�4 —SJUJV Inspx� Dide hopecdon