HomeMy WebLinkAboutWEC98-00103 - WEC Application - 5/11/1998 Mason County
14 p rtment of Health Services ; 4
A.
sJyf , i ST ACE SEAL CONSTRUCTION PERMIT Shelton, WA 98584
j9'4if Am!mPaid_gJ� (360) 427-9670
Receipt Number: FAX(360) 427-7798
FryTF Permit Number. 03
Instructions:
1. Ctmtpletepartone.
2. Payfae amp submit this application a minimum Of24be=in advance ofmitiating construction.
31 x 24he=prior to drilling the well,comect<the healthdepattntattt to give u0blivifion ofstormg
Pax to(360)427-7798 or Telephone(360)427-'9670 Extemiou350,
4. Atlaohplotplan.
PART 1: Applicant/Parcel Identification
Site House Address: c
4 o Stag Card#: IiLJ
Drilling Firm Name: ` ` 1% Telephone
Owner's Name: Ina
p IL1, '�/1/l' Telephone#:
Mailing Address: &Ad` "
8 y
Assessor's Parcel Number: ��� .��-� d—���
Subdivision(Ifapplicable): Div BlkLot_
Directions To Site:
PART 2: Heath Department Review(Staff Use Only)
TAG#: Date Called In: — YES
........................ . . . . . . . ❑
Is the well capped&vented? .. . ............................. .. ........ . ... ❑
Is there evidence of surface seal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Is there a continuous seal surrounding casing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑
Has the seal slumped?. .. . . ❑
Is the well flowing or is there evidence of other leakage? ❑
Is there evidence of cascading water? . . . . . . . . . . . . . . . . . . . .q�
Is Were evidence that the seal is at least 18 feet long'! .N.C. .8H4'
Do We well site set-backs appear to be appropriate? . . . . . . . . . . . . . . . . . . . . . . . , "CQ' ❑
PART 3: Conclusions y
Inspector Comments: TYG- OM g,'YFT— •vtJ 1]a �11�— wtepY CAY1M].f l' Xr /
` NC) —t( FrPr gam !nM3= Ox17y.-
�{[ Well Co tion Satisfactory ❑ Well Construction Unsatisfactory
Inspector Sigotture
Date
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