HomeMy WebLinkAboutWEC96-0193 - VAR Application - 7/30/1996 MASON.COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 16"
SHELTON, WA 9W8
12061 427--9670
FAX 427--7798
WELL CONSTRUCTION PERMIT
Receipt No: LOM . L� ..
Date of Payment:
INSTRUCTIONS JUL 2 9 19(
1. complete Part one.
2. Pay S60 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 PP (8:00 a.m..-500 4�p.m.) f
PART 1: ALICANT/PARCEL IDENTIFICATION U "� q` 01
..............................................................................................................................................................................
SITE HOUSE ADDRESS Off McMikken Road
DRILLING FIRM NAME Arcadia Drilling Inc START CARD NO. W069150
PROPERTY OWNER NAME William McCarty TELEPHONE (206 )776-8799
MAILING ADDRESS 20602 6th Place W Lynnwood , WA 98036
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ASSESSOR'S PARCEL NUMBER 3 5 3 3 5 - 2 3 - 9 0 0 2 0
SUBDIVISION (If Applicable) DIV _ BLK _ LOT _
DIRECTIONS FOR LOCATING SITE See Attached Sheet
ATTACH PLOT PLAN
DATE OF ANTICIPATED INITIATION OF WORK: 07-29-96
DATE OF ANTICIPATED COMPLETION OF WORK: O/_Z9_96
PART 2: DEPARTMENTAL USE ONLY
TIDEMARK NO.
CALL-IN DATE CALL-IN TIME AM/PM
START DATE START TIME AM/PM
COMPLETION DATE COMPLETIONTIM AM/PM
TAGGING AND SEALING SATISFACTORY? I__I Yea /o-J
COMMENT
INSPECTOR K7 DATE OF INSPECTION
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