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;fir _ -`,: <br /> SAN JOAQUIN LOCAL. FEALTH DISTRICT <br /> FOR OFFICE USE: U 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Permit No. 212,176i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE-'ISSUED , Date Issued IL14- 2 <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 i <br /> County Ordinance No. 1862 and. the Rules and Regulations of the San Joaquin Local Health District. <br /> 1112 <br /> JOB ADDRESS/LOCATION 1 N AZ'IEI RV' WELL # 1 CENSUS TRACT <br /> ' f <br /> Owner's Name CLARENCE DEN DULKPhone408--245-22 <br /> 46t <br /> Address lOb�O GROVELAND DR. CityLOS ALTOS 9 CAL <br /> Cbntractor's, NameHENNINGS BIOS. DRILLING COT. INC`. License 46116322 Phone,522-5643 <br /> TYPE OF WORK (Check) : NEW WELL/x/ DEEPEN -/_7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP .INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT /? 17 <br /> Other /_7 . <br /> r <br /> DISTANCE TO NEAREST: SEPTIC ,TANK SEWER LINES PIT PRIVY ,a <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER S i, <br /> INTENDED USE TYPE OF WELLr CONSTRUCTION SPECIFICATIONS <br /> � r <br /> Industrial Cable Tool Dia. of Well Excavation 2 <br /> Domestic/private Drilled Dia. of Well Casing , 16�sxa" <br /> Domestic/public Driven Gauge of Casingn - <br /> 3 Irrigation Grave]. Pack Depth of Grout Seal <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 /> '-PUMP REPAIR-:-. - ,./ j State Work-Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth i <br /> Describe`Material and Procedure <br /> I hereby agree to comply with all laws and-regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after 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 /> information is true to the best of my knowledge and belief. <br /> SIGNED -,_TITLE <br /> (DFrAW PLOT PLAN ON REVERSE SIDE) <br /> F i DE MENT USE ONLY . <br /> PHASE I -- <br /> APPLICATION ACCEPT Y ATE �f <br /> ADDITIONAL COMMENTS: <br /> 4 PHASE II GROUT INSPECTION WOE Al/ AL INSPECTI 7 <br /> INSPECTION BY DATE I DATE -/ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> C E H 1426 4/72 1M LXI� <br />