HomeMy WebLinkAboutWEC96-0309 - WEC Application - 11/18/1996 MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SHELTON, WA 98588
(206) 427-9670
FAX 427-7798
WELL CONSTRUCTION PERMIT .t(.t�V L-&j
Receipt NO: NUY 1 8 199b
Date of Payment: I IV2I SERVO '
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
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SITE HOUSE ADDRESS
DRILLING FIRM NAME .L T1-i 111,4 i1ni,o km r/{ a START CARD NO OSSg4,5
PROPERTY OWNER NAME alruhr�, ic, S(O Uh Q TELEPHONE *,?oL) s37-�7P Z
MAILING ADDRESS 3 . Q
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ASSESSOR'S PARCEL NUMBER ;' � L
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SUBDIVISION (If Applicable) 7724&^1If 9 DIV _ BLK _ LOT aL
DIRE( IONS FOR LOCATI G SITE �+tt� E&-n -'hp ./Q
75 M i fi _ 3 ;
ATTACH PLOT PLAN
WWI 50 a :s 3o " /To rA e-r c ce Sr
DATE OF ANTICIPATED INITIATION OF WORK: -'94+.
DATE OF ANTICIPATED COMPLETION OF WORK: �T i>-�kPP
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
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TAGGING AND SEALING SATISFACTORY? 1__I Yes U NO
COMMENT
INSPECTOR DATE OF INSPECTION
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