HomeMy WebLinkAboutWEC2000-00213 - WEC Application - 11/21/2000 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
SERVE
ACE SEAL CONSTRUCTION PERMI7M Box 1666 SHELTON,WA 93584
2 i xrir�1 LOCAL CMO)42?A670
T BBLFAIR(360)X75407
KWAS MCE CENTEif R°0e p, FAX(360)427-7798
Date�'TIDEMARK# urt
Instructions
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PART 1: ApplicanUParcel Identification
Sue House Address D') D E 04-e1 " CMAC O' Start Card# w 6 5 3 S
Drilling Firm Name To 0 0 0 0 LL L 1 J V 6 0 Telephone# 3 L O -2? � -? S'y
property Owner Name S rk 11% 0 lit � 4 ti c In Telephone# 3
Malting AddressT—
c _ wIN 19IT,
12
Assessor's Parcel Number ' -' -' ca '^ O O " O
Subdivision(If applicable) Div_Blk_Lot_
p���y To Site eQ 2 f C- rc[LC t>
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PART 2: Health Depa ent Re. iew (Staff UseOnly)
TAG# 1 YES NV
Drilleron site?...................................................................................................................... ❑
Isthe well capped&vented?................................................................................................ E I ❑
Is there evidence of a surface seal? ............... ❑
....................................................................
Is there a 2"annular space on all sides of the casing? ..................................................... o j
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-banes wear to be appropriate?....................................................... "/ ❑
Pass...................................................................................................................................... HH ❑
Com Celled In
/oI/cc
l r Date of Inspection