HomeMy WebLinkAboutWEC97-0215 - WEC Application - 8/21/1997 MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST 427-9 584
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SHEL FAX 427-7798
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.A WELL CONSTRUCTION PERMIT
\M�,1 I Receipt No:
Date of Payment:
IN
. complete Part one.
2. Pay $40 fee and submit this application a minimum of 24 hours in advance of initiating construction. Make check
payable to: Mason County Treasurer
3. Attach plot plan.
4. 24 hours prior to drilling-the well, contact the health department to give notificatio of starting. Fax to: 427-
7798, or Telephone: 427-9670 ext. 358 (8:00 a.m.-5:00 p.m.)
PART 1: APPLICANT/PARCEL IDENTIFICATION
SITE•HOUSE •ADDRESS:...............................................:: :.....................................................
............................................... ..................... .
DRILLING FIRM NAME EV'c ^�'1 ,/� START CARD NO.L fl A
Ri ,.c PROPERTY OWNER NAME ) e. (1 i ' TELEPHONE L) ) S1L0'
MAILING ADDRESS %t2
M ±A$4-i'
ASSESSOR'S PARCEL NUMBER ip. - - --
SUBDIVISION (If Applicable) /JDIV/ _ BLK _ LOT
DIRECTIONS FOR LOCATING SITE a 1' J /]pose d/'f
ATTACH PLOT PLAN
DATE OF ANTICIPATED INITIATION OF WORK: 7-fl'
DATE OF ANTICIPATED COMPLETION OF WORK: 67
2: DEPARTMENTAL USE ONLY
TIDEMARK NO.
CALL-IN DATE CALL-IN TIME AM/PM
START DATE START TIME AM/PM
COMPLETION DATE COMPLETION TIME AM/PM
TAGGING AND SEALING SATISFACTORY? u Yes U No
COMMENT
INSPECTOR DATE OF INSPECTION
H:\WDATA\ARCHIVE\WELL-IH2.W
REVISED 01/07/96