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WELL/PUMP PERMIT <br /> SAN IOAQUIN 304 WEBER AVE,, STOCKTON CA 95202 PUBLIC HEALTH SERVICES ENVIRONMENTAL 09)468-3420 ALTH DIVISION <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> 748. S, WALKER Wo 21 <br /> YOB ADDRESS " <br /> ST[1CK1'ON 115215 <br /> PARCEL SIZEIAPN <br /> CITYIZIP <br /> OWNERNAME HURB KEENER ADDRESS /48 5'. WALKER <br /> CITY/Z1P <br /> S'TOCKTON 9 215 PHONE 466,.5903 -i <br /> CONTRACTOR NOACK ADDRESS 45(TO E. EREMONT STREET <br /> CITYIZID STOCKTON, CA 95215 PHONE 948-8817 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: M WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW 11REPAIR H.P._1 DEPTH PUMP SET - FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> - <br /> M DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DTA <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING 24 HR N(DTI CE OUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX [ISTOVE PIPE R E CZ�U E ST ECONCRETE PEDESTAL BY DRILLER OYES ❑NO <br /> APPROXIMATE WELL DEPTH � ��-�-- <br /> �C)N5 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIANCES STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> i <br /> SIGNED: <br /> TITLE: R E TA X'L SAQ E DATE: 10 3 U O P <br /> c <br /> J0.01)Nr . ( <br /> ;v <br /> 1A Z <br /> DEPr1RTMENT USE PNLY <br />