HomeMy WebLinkAboutWEC96-0060 - WEC Application - 3/21/1996 MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX I666
SHELTON, WA 9
'"VIASON COUNTY HEALI H SERViCcg (206) 427-9670
P. O. Box 16bG FAX 42 7-7798
Shelton, WA 98584
WELL CONSTRUCTION PERMIT , D M R Q T 152 D
Receipt NO: _.1e:ki;
Date of Payment: (Q MAR �9U
0 6
INSTRUCTIONS
1. Complete Part One. 4FALTH SERVICED
2. Pay $60 fee and sulxnit this application a minimun 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
................................................................................................................ .... ......
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SITE HOUSE ADDRESS �C�\Tt C,c���� L� �,U S�zTo1Y
DRILLING FIRM NAME IJ� I( S UIZ(LLI )1J START CARD NO. Q D 6g2.6-)
PROPERTY OWNER NAME t/ /YA YWoSZ)AL� TELEPHONE (Y60) Ya7 — 2'f8
MAILING ADDRESS 7w-/ w G 5T
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ASSESSOR'S PARCEL NUMBER Z 3 - 2-
SUBDIVISION (If Applicable) DIV BLK 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
.........:...........................................:.....:.......................................
TIDEMARK NO.
CALL-IN DATE CALL-IN TIME AM/PM
START DATE START TIME AM/PM
COMPLETION DATE COMPLETION TIME AM/PM
AW C!G l-,
TAGGING AND SEALING SATISFACTORY? ,S^�Yes U No
COMMENT
INSPECTOR DATE OF INSPECTION