The URL can be used to link to this page

Home My WebLink AboutWEC2004-00251 - WEC Application - 12/15/2004 MASON COUNTY DEPARTMENT OF HEALTH SERVICES SURFACE SEAL CONSTRUCTION PERMITpO Box 1666 SHELTON, WA 98584 �B$LOCAL(360)427-9670 Cffl=R E C C I V 60)271-4461 RccciptpNoCly�i( 7 p0)427-7798 TIDEMARK#/ �t7N DECDate of � 15004 Instructions 426 Wf CEDAR STI h ComPlPart§f 2 t'aYfge and ugrtalt iTs aR Caborl am nfmum i312 f Wig rs'6moance.ofarigo*cQnstr-W tylaf�oheck paYab(e#a�1A�5gtQ�q�1�T,'i`'f'1ZF�lREf,1s` � s� 9 ?Ahou prio sfrlllfR&fh� eu +�ntachde(� ~p�ttetltN4tdti�c�$PnPtBtading � �j3&p)4?7* 9§ dr Te)e�one{§§� F�670�egsTol 283' ` f 5 rARM PART 1: Applicant/Parcel Identification Site House Address 11 E Mikkelsen Road Start Card# W1 86375 Drilling Firm Name Arcadia Drilling inc. Telephone# 360-426-3395 Property Owner Name Don Inzunza Telephone# 360-426-3731 Mailing Address PO Box 2354 Shelton, WA 98584 Assessor's Parcel Number _3 2 13 4 - 3 4 - 0 0 0 2 0 Subdivision(8 applicable) Div_Blk_Lot Directions To Site Northbound on Mason Lake rd Take a right on Mikkelsen Road- it,; is the 1s lot on left which corners Macon Take Road and Mikkelsen Road- PART 2: Health Depart e t Review (Staff UseOnly) TAG# � 773 YES NO / Drilleron site?...................................................................................................................... ❑ We Isthe well capped &vented?................................................................................................ d/ ❑ Is there evidence of a surface seal? ................................................................................... a,, ❑/ Is there a 2"annular space on all sides of the casing? ..................................................... ❑ Hasthe seal slumped? ....................................................................................................... ❑ f9� Is the well flowing or is there evidence of other leakage?.................................................. ❑ Is there evidence of cascading water? ............................................................................... ❑ [a-,,Is there evidence that the seal is at least 18 feet long? .................................................... l� ❑ Do the well site set-backs appear to be appropriate? ....................................................... ❑ i Pass...................................................................................................................................... ❑ Cg/ Comments Called in l Dr �5 ( - L OS" Inspector Date of Inspection