HomeMy WebLinkAboutWEC96-0281 - WEC Application - 10/16/1996 i
MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SHELTON, WA 98588
(206) 427-9670
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F(A�X 427-7798
WELL CONSTRUCTION PERMIT L R R O W R r� �
Receipt No: 699 OCTDate of Payment: C (�
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199
INSTRUCTIONS 4FALTH SERVICE,
1C
1. CwpLete Part One.
2. Pay S60 fee and submit this application a minimum of 24 hours in advance of initiating construction. Make check
payable to: Mason Canty Treasurer
3. Attach plot plan.
4. 24 hours prior to drilling the well, contact the health department and provide start card number using one of the
following methods: Fax to: 427-7798, or Telephone: 427-9670 ext. 352 (8:00 a.m.-5:00 p.m.)
PART 1: APPLICANT/PARCEL IDENTIFICATION
SITE HOUSE ADDRESS E 441 Mikkelsen Road Shelton
DRILLING FIRM NAME Arcadia Drilling Inc START CARD NO. W072837
PROPERTY OWNER NAME Linda Combs TELEPHONE (360 )427-4404
MAILING ADDRESS SE 30 Bay East Drive Shelton, WA 98584
1 Y 5tate zip
ASSESSOR'S PARCEL NUMBER 1 2 1 3 4 - 1 3 - 9 0 1 0 0
SUBDIVISION (If Applicable) DIV BLK LOT
DIRECTIONS FOR LOCATING SITE See Attached Man
ATTACH PLOT PLAN
DATE OF ANTICIPATED INITIATION OF WORK: 10-18-96
DATE OF ANTICIPATED COMPLETION OF WORK: - -
PART 2: DEPARTMENTAL USE ONLY
TIDEMARK NO.
CALL-IN DATE f,� x CALL-IN TIME AM/PM
START DATE START TIME AM/PM
COMPLETION DATE COMPLETION TIME AM/PM
TAGGING AND SEALING SATISFACTORY? Yes U No
COMMENT Aca..330
INSPECTOR DATE OF INSPECTION