Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGA <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described This application is made in compile <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> / Assessor's <br /> WELL Locatlon� 7 /J7+� C&k Cross Street PV�tFia" City, I/� �_zip�Paroel# !� <br /> PROPERTY Owner `PZ Address /63 6&'64-t'621 City R If Al Zip 20J Phone# 2-0t <br /> C-57 Contractor ; R.�I� el Address 231GS- gid" (,k Cdy sJ�lPA Zip W�`LIc#E�Phone#_ <br /> Consultant/Suis Contractor. _Address9.P City�Ic# S13 b-'J-? Phone# rlC <br /> GIS Coordinates XW ;?/f Vn I ,Y �6SB:drI`f ,Township jA,-- -Range- 6 E Section fl, <br /> WORK TO BE PERFORMED <br /> Q NEW WELL I BORING(CPT.GEOPROBE,HYDROPUNCH HAND-AUGER OTHER-) XDESTRUCTION(choose t, <br /> [I SOIL BORING# kDVER-B <br /> WELL# <br /> ,�! PRESSI <br /> 'Other Grout Specirimhons Are l"4 e of S. <br /> COMMENTS & <br /> - -- -- MfOVAr I AyInM TYPF CONSTRUCTION SPECIFICATIONS <br /> - p NO WELL CASIN( <br /> WESTERN GEO-ENGINEERS 5932 EEL p PVC p OTHE <br /> 1386 E BEAMER ST(530) 6s8-5300 3E USED []AUGERS <br /> WOODLAND,CA 9ST76$003 Date-/—&!- 2 11-3511210 M FREE-FALL DEF <br /> 52 <br /> Pay to the e �J tAFFIC BOX or STC <br /> Order of ��vt ��c'- �ff�' /� � � <br /> � L��� ecifcations here} <br /> �'1e 6 i <br /> Ban Iii ofAlmerFca, " oliars e <br /> Waodia"d f� valued Customer ENT PERMITS. <br /> 50 W Mer"St ave-Z$.e.-a <br /> WooW�'cs°s�a ��+r� � UFRE© INSPECTIO <br /> For i?r.�r ��� <br /> --�� � ---- ---'P Drdance with San J <br /> 1: 4 2 X000 3 581: 5 9 3 211-00 5 H311-0 O L 211! <br /> Signed __ erre-.- - _ ae� rxE <br /> Pnnl Nape-'- <br /> a �_� e _C_._-�__ _ 4 _..,.. _ Date /il- /AP-aZ <br /> DEPARTMENT USE ONLY <br /> SIVE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction inspection By Date <br /> COMMENTS 1 CONDITIONS <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# 11 <br /> SRA <br /> C-57 WC -WAIVER C-57 Letter of Authorization +riounn nerr.,r+ A— <br />