HomeMy WebLinkAboutWEC96-0311 - WEC Application - 12/16/1996 MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX I666
SHELTON, WA 99588
(2% 427-9670
FAAXX 427-7798
WELL CONSTRUCTION PERMIT
Receipt No:
Date of Payment: ;OV 2 1
INSTRUCTIONS ' 77O
'.TH SERA('
1. Complete Part One.
Z. Pay MO 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 comber 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. — Q ............
........................................................................::�.........................................
SITE HOUSE ADDRESS E 562 Catfish Lake Road
DRILLING FIRM NAME Arcadia Drilling Inc START CARD NO. W072852
PROPERTY OWNER NAME John Buttles TELEPHONE (360 )426-4663
MAILING ADDRESS PO Box 319 Allyn , WA 98524
City a e zip
ASSESSOR'S PARCEL NUMBER 3 2 1 3 4 7 5 _
SUBDIVISION (If Applicable) DIV BLK LOT
DIRECTIONS FOR LOCATING SITE Spp Attached Map
ATTACH PLOT PLAN
DATE OF ANTICIPATED INITIATION OF WORK: 11-21-96
DATE OF ANTICIPATED COMPLETION OF WORK: 11-21-96
PART 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
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TAGGING AND SEALING SATISFACTO Y? ItYas u No
COMMENT �,4�J
cos
INSPECTOR DATE OF INSPECTION
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