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Home My WebLink AboutWEC2004-00242 - WEC Application - 11/24/2004 MASON COUNTY p DEPARTMENT OF HEALTH SERVICES SURFACE SEAL CONSTRUCTION PERMITFO Box 1666 SHELTON, WA 98584 LOCAL(360)427-9670 BELFAIR(360) 275-4467 RmciptNo. _ FAX(360)427-7798 TIDEMARK#Date of �!21 c �� RECEIVED Instructions NOV 2 4 2004 1 ca pl@te pprtl7er d26 CEDAR ST9 2 F'a�tge en��dbm)t3bF�ap cpDon �fnitnum a)'�24�euss in aAvence ofir)�bartggeonstnt�lo� 3 24 ouls�pda �it1ll(rtg�lt} n at�teat��raro�ca6pamtst�rbn� 4 Attactr�leftilan • <.�w �; .. y ��.� � �` , •: PART 1: Applicant/Parcel Identification Site House Address Mikkelsen Road Start Card# W186373 Drilling Firm Name Arcadia Drilling Inc. Telephone# 360-426-3395 Property Owner Name Andrea Fontenot Telephone# 360-432-8967 Mailing Address 120 State Ave NE #247 Olympia. WA 98501 Assessor's Parcel Number 3_ 2_ 1_ 3 4 _- 3 4 - 9 0 Q 3 2 - Subdivision (It applicable) Div_Blk_Lot_ Directions To Site See Ba k o orner o Mikkelson and Macron L.akP ur D PART 2: Health Depart Revie (Staff UseOnly) TAG# Z YES NO Drilleron site?.................................................................................................................. Isthe well capped&vented?................................................................................................ Fd� ❑ Is there evidence of a surface seal? ............................ ..................................................... 11/ ❑ Is there a 2"annular space on all sides of the casing? ..................................................... l� ❑ 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? .................................................... G—}�/ ❑ Do the well site set-backs appear to be appropriate? ....................................................... L� ❑ Pass.....................................................................................................................................�,\ �❑ Comments Called in Inspector Date of Inspection I I � - �Y t O d co LFY'`L ) to y Y CD t 0 re 59 C W �XCY yy F *� F cn {