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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OP"FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �-W-7J <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.Orantline Rd.- 4004 East of Hansen 6WVS TRACT <br /> Nor side <br /> Owner's Name John Huber Phone 415-447-8913 <br /> Address 376 Helen Way City Livermore <br /> Contractor's Name Hennings, Bros. Drilling CO. Inc. License # 290813 Phone 522-103. <br /> 2300 W. Rumble Rd., Mod.. <br /> TYPE OF WORK (Check) : NEW WELL /X7 DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <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 /> T INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 11I' <br /> X Domestic/private Drilled Dia. of Well Casing 611 nl R Sti . <br /> Domestic/public Driven Gauge of Casing _ 160 wall � <br /> Irrigation Gravel Pack Depth of Grout Seal 504 ` <br /> Cathodic Protection x Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slab -by MMer <br /> Geophysical Surface Seal Installed B : d r it I e <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. • <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: f / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <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 VIFTEEN 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 /> SIGNED TITLE <br /> 71 <br /> DRAW PWT PLAN 'ON REVERSE SIDE) <br /> , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE" <br /> AT" �? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PUkSE I I/I'INAL INSPF=ION <br /> INSPECTION BY DATE INSPECTION BY' IDATE <br /> 3/76 <br /> E H 1426 Rev. 1-74 <br />