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HomeMy WebLinkAboutWEC96-0102 - WEC Application - 5/14/1996 MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTON, WA 9*M .*. i.iA60Pe '�kJUNTYltEAL-f;--: 8EHVIC-.'3 (206) 427-9670 P. O. box toe.; FAX 42 7-7798 Shelton, WA S3-•34 WELL CONSTRUCTION PERMIT Receipt No: CT Date of Payment: - INSTRUCTIONS 1. Complete Part one. 2. Pay $60 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 number 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 U '-ci (� �s . ................................................. ........................... SITE HOUSE ADDRESS �' J / 4g,4n,yAt2L^z &,ec2EEiC rV -51*L./� V DRILLING FIRM NAME I)A Vf S (�2(�.[ A(l:� START CARD NO. W//��,D-2 `C,/I g PROPERTY OWNER NAME �i��NIT S�F C� TELEPHONE SF60 )yL6�^ 6�l13 „ew... MAILING ADDRESS L � �',Q/4f1t3r792y (' ss&� ten UStace i 1LY /P ASSESSOR'S PARCEL NUMBER 3 2- / 3 _ /� 1 _ © Q O C4 11) SUBDIVISION (If Applicable) DIV ELK LOT DIRECTIONS FOR LOCATING SITE / ATTACH PLOT PLAN DATE OF ANTICIPATED INITIATION OF WORK: DATE. OF .ANTICIPATED.COMPLETION OF WORK: . - PART 2.DEPARTMENTAL USE ONLY e9:ee .............................................. TIDEMARK NO. - CALL-IN DATE CALL-IN TIME _ AM/PM . START DATE START TIME 'AM/PM COMPLETION DATE COMPLETION TIME AM/PM ..TAGGING AND SEALING SATISFACTORY? -gYes "No - COMMENT far✓ INSPECTOR - DATA OF INSPECTION