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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F01~ OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-1 ul <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _11_X-77 <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 /> JOB ADDRESS/LOCATION 16215 W.Grantline Rd.- 9004 East of Hansen WCVS TRACT <br /> North side <br /> Owner's dame John Huber Phone 415-442-8913 <br /> Address 376 Helen Way City Livermore <br /> Contractor's Name Rennin s Bros. Drilling Co. Inc. License # 290813 Phone L22-1031_ <br /> 2200 W. Rumble Rd*2 Mod. i <br /> TYPE OF WORK (Check) : NEW WELL -X7 DEEPEN-/ / RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION f_1 PUMP REPAIR /-7 PUMP REPLACEMENT 17 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia. of Well Excavation lit,� )14X Domestic/private Drilled Dia, of Well Casing it <br /> Domestic/public Driven Gauge of Casing 16 <br /> Irrigation Gravel Pack Depth of Grout Seal 50I <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slab -by Owner <br /> Geophysical Surface Seal. Installed B d rib e <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: , / / state Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 1 <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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNER TITLE <br /> D W P ' T PLAN 'ON REVERSE SIDE ! ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I rr <br /> APPLICATION ACCEPTED BY DATE! <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PA&SE I I SINAL INSPEC41ON <br /> INSPECTION BY DATE INSPECTION BY' 'DATE <br /> r <br /> E H 1426 Rev. 1 -74 ' 376 2M <br />