HomeMy WebLinkAboutWEC2002-00207 - WEC Application - 10/22/2002 MASON COUNTY
DEPARTMENT OF HEALTH 5ERVICE5
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PO 8 66 SHELTON.WA 98514
SHELTON (360)427-9670
SURFACE SEAL CONSTRUCTION PERMIT OCT 2 2= FAX (360)427-7798
!� ELMA (360)482-5269
Receipt No. �+ a Vf�, � ELFAIR (360)275-4467
Date of Payment ATTLE (206)464-6968
TIDEMARK*-,,, �-0
Instructions /
1. Complete part one.
2. Pay fee and submit this application a minimum�u NTY hours advance of
initiating construction. Make check Payable to
LTH
SERVICES.
3. 24 hours prior to drilling the well,contact the health department to give
notification of starting
fax to(360)427-7798 or Telephone(360)427-0670 Extension 293.
4. Attach plot plan.
PART 1: Applicant/Parcel Identification 7��y�
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3 2 l Site House Address H'/11/� L � �O' -
AW6 Leif f rbV (r Telephone#3�e -�75 -4:V07
Drilling Firm Name,�,�. —
Properly Owner Name /+y//L� 'R TD !L K Q r2l s elephone#
Mailing Address
Assessors Parcel Number
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Subdivision(If applicable) Div_Bik_Lot
Directions To Site
PART 2: Health Department Review (Staff UseOnly) YES NO
TAG#
❑ ❑
Drilleron site? ................................:..............................................................................
.......
Is the well capped&vented?................................................................................................ ❑ ❑
Is there evidence of a surface seal? .............. ..
................................................................... a a
Is there a 2"annular space on all sides of the casing? ..................................................... ❑ ❑
Hasthe seal slumped? .......................................................................................................
Is the well flowing or is there evidence of other leakage?.................................................. 0 ❑❑
Is there evidence of cascading water? ............................................................................... ❑ ❑
Is there evidence that the seal is at least 18 feet long? .................................................... ❑ ❑
Do the well site set-backs appear to be appropriate? ....................................................... ❑ El
.....................................:....................................................................... ........................
Called in
Comments
Date of Inspection
Inspector
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