HomeMy WebLinkAboutWEC2002-00206 - WEC Application - 10/22/2002 MASON COUNTY 1-c.j3LE@illWE
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DEPARTMENT OF HEALTH SERVICES t
OCT 22 002 I '
SERv4-1FS
SURFACE SEAL CONSTRUCTION PERMITP° BOX 1666 SHELTON, WA 98584
LOCAL(360)427-9670
{� BELFAIR (360) 275-4467
Receipt No. acoci, U FAX(360)427-7798
Date of Payment 10 ai-{ -0 2,-,
TIDEMARK# LO C 0004— t.0
Instructions
1, Cornplete part one.
2 Pay fee and submit this application a minimum of 24 hours in advance of initiating construction.
Make check payable to MASON COUNTY TREASURER.
3. 24 hours prior to dulling the well, contact the bean department to give notification of starting
Fax to(360)427-7798 or Telephone(360)427-9670'Extension 293:
4. Attach plot plan.
PART 1: Applicant/Parcel Identification
' W. 2191 Ranks Lake Road W165398
Site House Address Start Card#
Drilling Firm Name Arcadia Drilling Inc. Telephone# 360-426-3395
Property Owner Name Robert Collins Telephone# 360-432-9631
Mailing Address W. 2191 Hanks Lake Road Shelton, WA 98584
Assessor's Parcel Number 5 2 0 0 1 - 7 8 - 0 0 0 3 0
Subdivision (If applicable) Div Blk Lot
Directions To Site
Please see attached map
PART 2: Health Department Review (Staff UseOnly)
TAG# YES NO
Driller on site? 0 0
Is the well capped &vented? 0 0
Is there evidence of a surface seal? 0 0
Is there a 2"annular space on all sides of the casing? 0 0
Has the seal slumped? ❑ ❑
Is the well flowing or is there evidence of other leakage? 0 0
Is there evidence of cascading water? 0 0
Is there evidence that the seal is at least 18 feet long? 0 ❑
Do the well site set-backs appear to be appropriate? 0 0
Pass 0 0
Comments Called in
Inspector Date of Inspection
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