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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO_6 OFFICE USE: 1.601 E. Hazel tofi-Ave ', <br /> Stockton, Calif. ` l' <br /> Telephone: (209) 466-•6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No- .7 <br /> THI'S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,;' <br /> (Complete In.Triplicate) <br /> Application is heriVy`-made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herain described. This- application is made in compliance with Sam Joaquin <br />' County Ordinance No. 1862 andithe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> 12352 W. Larch Rd. 1/4 Mile West of .Corral 9� RACT <br /> phone '415-443-0232. <br /> Owner's Name George T. 'Gibson <br /> 1562 FrankCit <br /> Frankfurt Way Livermore , Cal <br /> Address y " <br /> Hennings Bros Drilling Co. Inc'. L # ,290813 phone2500 52.2-1031 <br /> Contractor's Name � e 1 a 9. <br /> • 3 <br /> TYPE OF WORK (Check) : NEW WELL , DEEPEN '/ RECONDITION f DESTRUCTION 7 �--- <br /> PUMP INSTALLATION / I pump REPAIR /-7 PUMP REPLACEMENT �T <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 /> E INTENDED USE TYPE OF WELL , CONSTRUCTION SPECIFICATIONS Illy <br /> Industrial 1 Cable'-Tool - Dia. of Well Excavation _ sr <br /> xx Domestic/private Drilled Dia. of Well Casing 12 Ga <br /> Domestic/public I Driven < Gauge of Casing <br /> l Irrigation Gravel Pack _Depth of Grout Seal µ — <br />[ 1 entonite <br /> Cathodic Protection "� Rotary Type of Grout owner <br /> Disposal- 2 Other Other Information' a <br /> Geophysical Surface -Seal Installed 'B <br /> `PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> S.ta.te_Wor.k_Done;�.� <br /> PUMP REPAIR:. _ :�; �... -,-./�,f-�.4 . <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 /> and the State of California.pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on at'new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the Drell ad notify them before putting the.-wellin.use.. The above <br /> information is true to- the-vest-of..myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING 'AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> F(,)A.. 1APARTMENT USE ONLY <br /> PHASE I ,S <br /> DATE <br /> APPLICATIOACCEP <br /> N <br /> Y ADDITIONAL CO S: <br /> E I OUT INSPECTION E In I. INSPECTION r S <br /> f INSPECTIO DATE S INSPEC DATE <br /> 2M <br /> U IL9A 1_7G - <br />