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WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 748 $ WALKER PARCEL SIZE/APN CITY/ZIP STOCKI ON 95215 OWNERNAME HURB KEENER ADDRESS /48 S'. WALKER CITY/ZIP 5'TOCKTON 95215 PHONE 466-.5903 CONTRACTOR NOACK- ADDRESS 4590 E. FREMONT STREET _ CITY/ZIP S:TOCKTON, CA 95215 PHONE 948-8817 GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER INSTALLATION: M WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# TYPE OF PUMP: ❑ NEW CXREPAIR H.P. 1�.....- DEPTH PUMP SET FT. FIRST WATER LEVEL ❑OUT-OF•SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA E3 DOMESTIC PRIVATE ❑GRAVEL PACKISIZE WELL CASING TYPE.- WELL CASING DIA ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION ❑IRRIGATION/AG OTHER GROUT BRAND NAME ❑MONITORING 24 R R C E OUT SEAL PUMPED: ❑YES ❑NO ❑CHRISTY BOX ❑STOVE PIPE R E C)U EES-FE CDCONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO APPROXIMATE WELL DEPTH P1D"i ALL 1(-)NS PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. SIGNED: ^s TITLE: R E TA PL SA E DATE: 10 3 U 0 P c AJ DEPARTMENT USE NLY Application Accepted By Date Area Grout Inspection By Date Pump Inspected By Date, Q Destruction Inspection By Date COMMENTS: PE SC AMOUNT CHECK# RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# CODES INFO REMITTED ASH BY