HomeMy WebLinkAboutWEC96-0126 - WEC Application - 5/28/1996 �tC.tIVLu
MASON COUNTY DEPARTMENT OF HEALTH SERVICES MAY 2 4 1996
POST ptBFIC.460RX,1666
SHELT ON WA 98584
(3d0) 427-9670
FAX 427-7798
WELL CONSTRUCTION PERMIT
Receipt NO:
Date of Payment: J
INSTRUCTIONS
1. complete Part One.
2. Pay S40 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 notificatin 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 ....0.'U!.�...........
................................. ...................................................
SITE•HOUSE•ADDRESS••.•N" `� y g ••v��� u` ���� �/^` .10
�,Z
DRILLING FIRM NAME !C-&j)/�.i�,7Y 7,����-4 kZL C"=7 START CARD NO..
/�Aza 46PLA M6,0- TELEPHONE
PROPERTY OWNER NAME
MAILING ADDRESS
1L06M6OTA-tr �A� A
1 y 2 SL/at:e yip //J�
ASSESSOR'S PARCEL NUMBER ✓ 1.- - - 2 � �z2
SIIBDIVISION (If Applicable) DIV BLK _ LOTK
/L� /
DIREC ION FOR TING SITE
ATTACH PLOT PLAN
DATE OF ANTICIPATED INITIATION OF WORK: V
DATE OF ANTICIPATED COMPLETION OF WORK:
PART 2: DEPARTMENTAL USE ONLY
TIDEMARK NO,
CALL-IN DATE CALL-IN TIME AM/PM
START DATE. START TIME AM/PM
COMPLETION DATE �p/{D� COMPLETION TIME AM/PM
TAGGING AND SEALING SA rIISFACTORY? XYes U No
COMMENT C�iD rJill
DATE OF -INSPECTION
INSPECTO
H:I WDATA\ARCHIVE\WELL-IN2.W
REVISED 01/07/96