HomeMy WebLinkAboutWEC2000-00165 - WEC Application - 8/7/2000 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
SURFACE SEAL CONSTRUCTION PERMIT
PO BOX i 1666 S.HELTON, WA 98584
n.i L5 ° (� 3 4 8B PAR(360)275�70
Receipt No. ( t
Date of Pa ment FAX(360)427-7798
TIDEMARK#
Instructions 694:&
2 day�a and subr)t€tZftirs app,9cabcn aminimultt of 24,hcuis in ativance of in€datinq construction.
ylaKa otieoK PaY�b1e�4 MASOI?fr�OUNT�`7!REASUREf
� 2f}�oursPr'or#a�lsl�Ing tha�Qll,cot�aektha heath dePertmentm give naeficatiot of atarbng
•.Faxto�&50j'd27.X'798 or Tt"ephati.:a(060)427ti670 Mansion 364.
4 ! Attach Plot plan
PART 1 : Applicant/Parcel Identification
Site House Address v L cleol der- ZA. Start Card#
Drilling Firm Name T--Vesra rA C//em �¢` [ /r �� Telephone#
Property Owner NameIr 6i diet WI 1/.t/�/ / Telephone#
Mailing Address ��(�C Oa Wo WJJ /!Q C/I s/,,
vine;a U41.
Assessor's Parcel Number a lr 3 �i 2� 4 d
Subdivision(If applicable) Div_Blk Lot
Direc' ns To Site
e t < w4 la ✓e.t de
rriel,
Is the well site within 100 feet of satUsea water? Yes No 1C
If yes, a anance fr m DO i re luired. Have you applied/received(circle one) a variance?Yes_ No_
ApplidanUAgen ign reYX/�
PART 2: Health Department Review (Staff UseOnly)
TAG# 4 rrgz IL YES NO
Drilleron site? ...................................................................................................................... ❑ ❑
Is the well capped &vented?................................................................................................ ❑ ❑
Is there evidence of a surface seal? ................................................................................... ❑ ❑
Is there a 2" annular space on all sides of the casing? ..................................................... ❑ ❑
Hasthe 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 site set-backs appear to be appropriate? ........................................... .::G...... ❑
Comments Called ' D ��
inspector nspec on
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