The URL can be used to link to this page

Home My WebLink AboutWEC2002-00192 - WEC Application - 9/25/2002 y MASON COUNTY al L5 DEPARTMENT OF HEALTH SERVICES sEp 2 5 2002 SURFAC SEAL CONSTRUCTION PERMIT PO BOX 1666 SHELTON,WA 98584 No SHELTON (360)427-9670 S Cog/ 24 FAX (360)427-7798 Receipt No. �'e ELMA (360)482-5269 Date of Payment O BELFAIR. (360)275-4467 Instructions TIDEMARK# ( Ec_zca —2287 - SEATTLE (206)464-6968 PART 1:Applicant/Parcel identification Site House Address S &'?. T 544L�Vart Card#�`��7� -��f��J�Tj Drilling Firm Name t){f�tf7h.ZCS C ,l(i✓IC �� Telephone# Property Owner Name�fc`R;e) ON Telephone3�0 "--701 - E72D Mailing Address 5Z2� g0� �4tJt S(.J rmsl? Assessor's Parcel Number Z 1 _ t4 2 U Z O v Subdivision(If applicable) 'n Div�p Blk Lot Dia@ [ores to sit{ce-� 12o. Con 64C )4 i It r� T C _ IT drED e 255 1 , =T S ` ,5- j ��Jew^"-� is the well site within 100 feet of saWsea water? Yes No If yes, a variance from DOE is required. Have you applied�received(drde one) a variance?Yes No �U )e%c ._ — — Applk antCAgent Signature PART 2: Health Department Review(Staff Use Only) TAG# Called in YEs IS Drilleron site?...................................................................................................................... o Is the well capped vetriad?.....................................................................................:........... ❑ ❑ Is there evidence of a surface sea[?................................................................................... Is there a 2"tinnuiar space on all sides of the casing?..................................................... 9 8 Hasthe Seel slumped?.............................J......................................................................... ❑ ❑ Is the well flewhtg or is there evidence of other leakage?............................................. ... . Is theta evidence of cascading water?...................................................... ..... ........ 8 8 Is ffmm evo6rm#"iaf flee seal is et least l8 feet loth?....... .1 Do the wall site set-asks appear to be appropriate?............... ... ..„..... . �• Mf. ..N.. •� �. COfIYnEflt$�� (� ❑ fi Inspector Date of