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HomeMy WebLinkAboutWEC2004-00170 - WEC Application - 8/19/2004 MASON COUNTY RECEIVED DEPARTMENT OF HEALTH SERVICES AUG 19104 W. t ' SURFACE SEAL CONSTRUCTION PERMITPO Box 1666 SHELTON, WA 98584 LOCAL(360)427-9670 BELFAIR(360)275-4467 RccciptNo.v 7 t // FAX(360)427-7798 Date ofP}}ymnte �R/ TIDEMARK# fi W O Instructions 1 Cot(Ipltate paeG4n@ �% ` 2 PaytQe and gu�fpr�#a!s p eaboAttljq�lnuni of4 hpuls lsrasf4�nce ofintGatr4one4140a6 Ma gc�tsak�Yabfata�CetMq �iEtJRk'�#n a : ny 3 249u(spno�asfAllftl�'��rel4�s>xd11 aa(t�cJepa<tnla t fv@��tntifit�a6onm�8tar�ttg PART 1: ApplicanVParcel Identification She House Address Mason Lake Rd/Catfish Road Start Card# w181740 Drilling Firm Name Arcadia Drilling Inc. Telephone#360-426-3R95 Property Owner Name Mike & Robin Johsnon Telephone#360-438-7469 Mailing Address 3526 17th Way Olympia, WA 98501 Assessors Parcel Number 3 2 1 3 4 -3 0 - 0 _0_ Q- 0_ 0 Subdivision (If applicable) Div_Elk_Lot pptrectionsToch From Hwy L n ee Attached Map � 3 turn left on to Manson Lake turnoff lS P, iio4q t f atfi gh RnaA tarn right loolr for PART 2: Health Departm ent Review (Staff UseOnly) TAG# AI�-N6�-63 YES NO Drilleron site?...................................................................................................................... ❑ Isthe well capped 8 vented?................................................................................................ )j�r ❑ Is there evidence of a surface seal? ................................................................................... ❑ Is there a 2" annular space on all sides of the casing? ..................................................... ❑ Hasthe seal slumped? ....................................................................................................... ❑ 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 to be appropriate? ....................................................... ❑ Pass...................................................................................................................................... ❑ CMzz;�—E— Called in / 0 —'/9 11Z((6/oil Inspector Date of Inspection