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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> V) 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 -S,-,j/- <br /> (Complete <br /> ssued _?-j/-(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.- 900' East of Hansen MZVS TRACT <br /> Nortn side <br /> Owner's Name John Huber Phone 1+15-1+47-8913 <br /> Address 376 Helen Way City Livermore <br /> Contractor's Name Rennin s Bros. DrillingCo. Inc. License # 2 081 Phone 522-1031 <br /> 2 00 W. Rumble Rd., Mod. <br /> TYPE OF WORK (Check) : NEW WELL /I/- DEEPEN '/ / RECONDITION / / DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR f—/—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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia. of Well Excavation 11" <br /> A Domestic/private Drilled Dia. of Well Casing Eng ctie <br /> Domestic/public Driven Gauge of Casing _ 160 wal <br /> Irrigation Gravel Pack Depth of Grout Seal 500 ` <br /> Cathodic Protection R Rotary Type of Grout Bentonite \� <br /> Disposal Other Other Information Slab -by owner }� <br /> Geophysical Surface Seal Installed By: iller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <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 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 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 /> SIGNED TITLE <br /> !DRAW PIST PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ///JJJ n J <br /> APPLICATION ACCEPTED BY �/f�G .,� DAT)' �a ZT <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SE I IjFINAL INSP° CION <br /> INSPECTION BY DATE INSPECTION BY' DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />