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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 -­OF'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. =14d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 90SyS TRACT <br /> Nortli side <br /> Owner's Name John Huber Phone 415-1+1+2-8913- <br /> Address <br /> 1 -41+ -8Address 376 Helen Way City Livermore <br /> Contractor's Name Hennings Bros. Drilling Co. jnc. License # 290813 Phone122-1031 . <br /> 2500 W. Rumble Rd. Mod. i <br /> TYPE OF WORK (Check) : NEW WELL IKI- DEEPEN '/—/ RECONDITION_/ / DESTRUCTION /'7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <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, <br /> X Domestic/private Drilled Dia, of Well Casing 611 P-1astl <br /> Domestic/public Driven Gauge of Casing 160 wall <br /> Irrigation Gravel Pack Depth of Grout Seal 50" i <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slab -by gyner <br /> Geophysical Surface Seal Installed By: driller <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 11 <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 Heath 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 Pig T PLAN 'ON REVERSE SIDE) �a s <br /> 41 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I t <br /> APPLICATION ACCEPTED BYDATE -- f, -- <br /> ADDITIONAL COMMENTS: ° <br /> PHASE II GROUT INSPECTION P9,kSE I I/T INAL INSPWJION <br /> INSPECTION BY DATE INSPECTION By, 'DATE <br /> v 3 <br /> 3/76 2M <br /> E H 1426 Rev. 1--74 <br />