Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ORIGINAL <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 compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. o9O <br /> W 4 Assessor's <br /> WELL Location 27 SFS)n4*%1 St-ree Cross S Ra CityStoc (ori Zipc1SZo3 Parcel# <br /> PROPERTY Owner EP— 6 RC-O Address City Zip Phone# / <br /> C-57Contractor\A/Plr 14aay,,A+ Address3ZZ9 P'itjz vr•ald Rdtv6C' 4 _ -5 7 <br /> ;ty �or.thoZ;pgS74�ic#Ss4j7y Phone#M 1, 16 <br /> 38`?Z?6 <br /> Consultant/Sub ContractorSELCt;' -t cnnl Address&t7 K6G^e Rd, Sic IubCRav\Ch <br /> ity Gc dc�r Lic#` Phone#(4[6186j-Dy("0 <br /> GIS Coordinates:X Y Township k N Range 6 C Section <br /> WORK TO BE PERFORMED: <br /> V,NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) []DESTRUCTION(choose type below) <br /> []SOIL BORING# []OVER-BORE <br /> WELL# 15—1/ ZS-Zif .ZS-3_� I/YI(,U—S� �ie�Z—M40— C� "IZ [] PRESSURE GROUT <br /> "Other: Grout Specifications: <br /> COMMENTS: X 5`i— 2 <s-w ' u �t iafilS 47 Z e) LI&L—&i? <br />