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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .FOR OFFICE E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1 a 4 <br /> (Complete In Triplicate) <br /> Application is hereby.-made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOS ADDRESS/LOCATION UNTALLEN :RD_.� WELL # 3 CENSUS TRACT 5-'07 if, <br /> Owner's Name CLARENCE DEN DULK r <br /> Phone �1.0$���+�»-229$ <br /> Address 10670 GROVELAND DRIVE City LOS ALTOS CAL <br /> 1 <br /> Contractor's Name HFNNTNG,c;-B , .DRILLING COk, „INC._. License # 116322 Phone 522 61l <br /> TYPE OF WORK (Check) : NEW WELL /,7 DEEPEN / / RECONDITION /-7 DESTRUCTION /7 i <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other / / <br /> 2 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL •FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> A <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 2 <br /> Domestic/private Drilled Dia. of Well Casing lberx�i� <br /> Domestic/public � Driven Gauge of Casing <br /> x - _- Irrigation Gravel Pack Depth of Grout Seale <br /> Other X Rotary Type of Grout <br /> Other Other Information <br />,.PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> jAr <br /> PUMP REPAIR:. /�.-.State Work-Done <br /> y � <br /> ,DESTR.UCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hI hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> sand the 'State •of California pertaining to or regulating well construction'. Within FIFTEEN DAYS <br /> kafter completion of my work on a new well, I will..furnish the San Joaquin Local Health District a <br />� WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> informati is true to the best of .my knowledge and belief. .w <br /> SIGNED TITLE <br /> (DR49 PLO PZ N REVERSE SIDE <br /> i �__MLDEPN 4ENT USE ONLY <br /> `PHASE -I <br /> APPLICATION ACCEPT ATE <br /> ADDITIONAL COMMENTS: <br /> l PHASE II GROUT INSPECTION P I F AL INSPEC. ON <br /> , INSPECTION BY DATE INSP DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />