HomeMy WebLinkAboutWEC95-0140 - WEC Application - 6/6/1995 MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POIST OPPRE BOE I"s
SHJMMN. WA MW
FAX 42�
WELL CONSTRUCTION PERMIT j ' (�
Receipt No: �UJ
Date of Payment: ! , A 0 6 1995
INSTRUCTIONS {{ ,,eeg t�ipa,i�
1. Complete Part One. _!CAI TW RP'�- `Ij(%FC
2. Pay 160 fee aril submit this application a minimum of 24 hears in Advance of Initiating constriction. Make eMell
payable too Masan county Treasurer
3. Attach plot plen.
4. 24 hours prior to drilling the wll, contact the health department end provide start•eerd rnmber using No of, the
following methods: Fax to: 427-7M, or Telepham: 427-9670 ext. 352 (es00 s.m.-9:00 p.m.)
PART 1: APPLICANTIPARCEL IDENTIFICATION
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SITE HOUSE ADDRESS E . 90 E. Effie Prosser Road
DRILLING FIRM NAME Arcadia Drilling Inc START CARD No. W062303
PROPERTY OWNER NAME Nancy L . Crocker TzLgpgON
E (3601391-4721
MAILING ADDRESS 4722-231st . Avenue SE- Issaquah, ,-WA 98027
ASSESSOR'S PARCEL NUMBER 3 3 6 - 1 4 _ 9 0 0 7 0
SUBDIVISION (If Applicable) DIV _ ELK LOT _
DIRECTIONS FOR LOCATING SITE 4 NE 1 4 S-36 T-21N R-3W
See Attached Sheet
r: ATTACH PLOT PLAN
DATE OF ANTICIPATED INITIATION OF WORK: 06-08-95
DATE OF ANTICIPATED COMPLETION OF WORK: 06-08-95
i,. PART 2: DEPARTMENTAL USE ONLY
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TIDEMARK NO.
t CALL-IN DATE CALL-IN TIME AN/PM
START DATE START TIME AN/PN
COMPLETION DATE COMPLETION TIME .AM/PN
1 '160
TAGGING SEALING SATISFACTORY? ❑Yee 13 No
COMMENT
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