HomeMy WebLinkAboutWEC2000-00156 - WEC Application - 8/10/2000 MASON COUNTY DEPAERTMENT OF HEALTH SERVICES
SURFACE SEAT;CONSTRUCTION PERMIT
POST`OFFIC>*BOX- 1666
SIELTON; VITA- 995$4
Local (360) 427-9670
Receipt N Belfair(360) 275-4467
Date of Payment- FAX 427-7798
TIDEMARK% �
INSTRUCTIONS �01
PART I:APPLICANT/PARCEL IDENTIFICATION
SITE HOUSE ADDRESS 751 TRUDEAU MT.LN.
DRILLING FIRM NAME COOLWATER DRILLING. START CARD 117
PROPERTY OWNER NAME JOANNE FERGRSON TELEPHONE i��cCC y'1' D
MAILINGADRESS 751 TRLTDEAU MT.LN..
BELFAIR,WA. 98528 AUG 9
ASSESSOR'S PARCEL NUMBER 2230-2-75-00130 HEALTH SERVICES
SUBDIVISION(IF APPLICABLE) DIV- BLK LOT_
DIRECTIONS FOR LOCATING SITE SEE MAP
Is the well site within 100 feet for salt/sea water? Yes No X
If yes,a variance from DOE is required. Have you-apphed/received(circle one)a variance? Yes No T
Applicant/Agent Signature
PART 2: Health Department Review stafflzeOnly)
TAG# YES NO
Drilleron site?.......................................................................................................................................... ❑ ❑
Is the well capped&vented?..._....................._...__.._.._. ............
Is there a 2"annular space on all sides of the casing?.............._................................................................. ❑ ❑
Has-the scatdmrped?............................................................................................................................... ❑ ❑
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 be appropriate?...................................................................................... ❑ ❑
COMMENT
INSPECTOR DATE-OF INSPECTION