HomeMy WebLinkAboutWEC96-0123 - WEC Application - 5/22/1996 MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SHEL TON,
WA 98588
(206) 427-9670
FAX 427-7798
WELL CONSTRUCTION PERMIT c t C t i v r:
Receipt No:
8 MAY 2 2 iY9b
Date of Payment: 1I_TH SF.RVICr-
INSTRUCTIONS
1. Complete Part One.
2. Pay $60 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 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
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SITE HOUSE ADDRESS 7G � 1 ' So/l Z , /' /ypLcaCcci W4 g
DRILLING FIRM NAME Le4f
V/e I inC' START CARD NO. W O/pOPROPERTY OWNER NAME �lV JV t ('�' TELEPHONE
MAILING ADDRESS
sn � (-VA lfQtU,�'Q-
`'`SL�3fe—Zip
ASSESSOR'S PARCEL NUMBER
SUBDIVISION (If Applicable) Sl)A / DIV ELK LO/Tw
DI ECTIONS FOR LOCATING SITE ]'�G hYl /'( /it A /I p,
Al ✓r r ; q S 6'bo7if
S /5l0 S J,e �/
ATTACH PLOT PLAN
DATE OF ANTICIPATED INITIATION OF WORK: �—jD •—�/
DATE OF ANTICIPATED COMPLETION OF WORK: —7 �L
PART 2: DEPARTMENTAL USE ONLY
................................................
TIDEMARK NO.
CALL-IN DATE
START DATE CALL-IN TIME AM/PM
START TIME AM/PM
µ^N
COMPLETION DATE Q /3 COMPLETION TIME AM/PM
TAGGING AND SEALING SATISFACTORY? n
COMMENT Yes U No
E ;gINSPECTOR v
DATE OF INSPECTION
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