HomeMy WebLinkAboutWEC95-0318 - WEC Application - 12/27/1995 4 ti
..,A, ASQZ,�COUNT . E, PARTMENTqV,JW, ALTH,SERVICES
POST OFFICE BOX 1666
>" SHELTON, WA 91
(206) 427-9670
_t 1ASON COUNTY HEALTH SERVICES FAX 427-7798
P. O. Box 1666
,,'.. Shelton,WA 98584 -
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WELL CONSTRUCTION PERMTT
Receipt No:
Date of Payment:
INSTRUCTIONS =
1. Complete Part One. • „ r� „ r
2. Pay $60 fee and sutra this application a min mua 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 nnber using one of the
following methods: fax to: 427-7798, or Telephone:.427-9670 ext. 352 (8:00 a.m.-5:00 p.m.)
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PART 1: APPLICANT/PARCEL IDENTIFICATION
, SITE HOUSE ADDRESS T�ID ..7a' .........................................
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DRILLING FIRM NAME D6V/ S �(�l LL/N 19--- ' START CARD N0. "� U73�7
PROPERTY OWNER NAME �/?O 8)AI ✓ Ofl A/S D A/ TELEPHONE i bD )
MAILING ADDRESS •'�7�/� / [% //y1/l UnV N3L /ZJ
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ASSESSOR'S PARCEL NUMBER- 2. 3 �• - _4 /
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SUBDIVISION (If Applicable) ' -kh ) - DIV BLK LOT
DIRECTIONS FOR IOCATG SITE
. •a ATTACH PLOT PLAN
DATE OF ANTICIPATED INITIATION OF WORKS
DATE OF ANTICIPATED COMPLETION OF WORK
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PART 2s DEPARTMENTAL USE ONLY fk, � F
..............................
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TIDEMARK NO Y
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CALL-IN DATE ' +�, CALL-IN TIME:
START DATE ". c •, START::TIME :'AM/PM .'.
: .:COMPLETION DATE .:.•.::.COMPLETION TIME -AM/PM .:
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TAGGING AND.SEALING SATISFACTORY? 4w`t;,` 1 Yea ONO
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COMMENT
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INSPECTO
DA E OF" INSPECTION.