HomeMy WebLinkAboutWEC2005-00228 - WEC Application - 8/17/2005 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584
SHELTON (360)427-9670 ELMA (360)482-5269 BELFAIR (360)275-4467
WEB httD://www.co.mason.wa.us FAX (360)427-7798
APPLICATION FOR WELL SURFACE SEAL CONSTRUCTION PERMIT
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IrReceipt Number;,S /��(��aL7 " WEC: 00�—/ �
C'� y 1. Complete Part 1, incomplete applications will not be accepted
c
��� 1 2005 2. Attach a plot plan and vicinity map
OUN�. 3. Submit this completed application with appropriate fee(s)a minimum of 24 hours
MAgpN C in advance of initiating well construction.
Date Received 4. The Mason County Health Dept.must receive notification at least 24 hours prior to
the drilling of the well
(Ut PART 1:Applicant I Parcel Identification
Site Address � p_J2U IC Start Card#
Drilling Firm F 1241, Phone
Applicant (/1/� CD�L Phone
Mailing Address
City A4kur✓1 state WA zip 9$692
-- Parcel Number (� /
Directions to Site �-Aym Q, c! ax-
Is the wells within 1 eet of salt/seawater? ❑Yes RfNo
If yes,a va from E required. Have you applied/received(circle one)a variance? ❑Yes []No
Applicant/Agent Signature
PART 2:Health Department Review(Staff Use Only) 2
YES NO TAG# Called In 11
❑ ❑ Driller on Site?
❑ ❑ Is the well capped and Vented?
❑ ❑ Is there evidence of a surface seal?
❑ ❑ Is there a 2"annular space on all sides of the casing?
❑ ❑ Has the 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?
Comments
Pass Fail Inspector Date