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SAN JOAQUIN LOCAL HEALTH DISTRICT x <br /> FOR OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued/�- 7 <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. 1652 and the Rules and Regulations of the San Joaquin Local Health-District. <br /> 1 S s r <br /> JOB ADDRESS/LOCATION ALLE ARD WELL # 2 2�5� ��C <br /> ' YENSUS TRACT <br /> Owner's Name CLARENCE DEN DULK Phone 408-245-2298 <br /> Address 10670 GROVELAND DR. <br /> City LOS ALTOS, CAL <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC . License # 116322 Phone522-5643 <br /> TYPE OF WORK (Check) : NEW WELL /XT DEEPEN /-7 RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK TSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S <br /> Industrial Cable Tool Dia, of Well Excavation 2411 <br /> Domestic/private Drilled Dia. of Well Casing 16"xl" <br /> Domestic/public Driven Gauge of Casing'-___ <br /> _. _ Irrigation Gravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout S <br /> Other Other Information <br /> r. PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: J / State Work Done <br /> t <br /> PUMP-REPAIR.- f / State Work Done -- <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the. San Joaquin Local Health District <br /> c 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 lth District a <br /> t WELL DRILLERS REPORT of the well and notify, them before putting the well in--.6-se.­ he-ait ,e <br /> l information is true to the be t of my k,owledge and belief. <br /> SIGNEDTITLE' <br /> (PM PLOT PLAN ON REVERSE SID <br /> L:;� Z%— <br /> FOR DEPARTMENT US ONLY <br /> PHASE I <br /> 1APPLiCATION ACCEPTDATE <br /> . ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONP I NAL INSPEC ION v <br /> INSPECTION BY DATE INSPE DATE Ib <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> �,E H 1426 7/72 1M <br />