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I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FUE OF]?ICE USE: 1601 E. Haz�ltfn Ave . , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZLO�—S--/ . .k <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 /> ZQ <br /> JOB ADDRESS/LOCATION. �/ �. , �� _ CENSUS TRACT <br /> -'1 - - - --- - --..ate._ %�•_--- ---- - <br /> �M <br /> Owner's Name LEONARD ALEGRE' Phone 835-4621 <br /> �M <br /> Address= .202 , b S. LAMMERS RD. City TRACY <br /> Contractor's Name HP.MM1211 <br /> License # Phone }+ _ . <br /> \4 <br /> TYPE OFV`.WORK (Check) : NEW WELL. IXI DEEPEN"j/, / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / j; PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK l SEWER LINES PIT PRIVY r <br /> SEWAGE DISPOSAL FIELD �,? CESSPOOL/SEEPAGE PIT OTHER%.)6_/06 <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 _ 1 R'� <br /> X <br /> � Domestic/private Drilled Dia, of Well Casing - 8t, PLA <br /> Domestic/public 4 Driven Gauge of Casing _ 160 WALL <br /> Irrigation i $ Gravel Pack Depth of Grout Seal rot <br /> Cathodic Protection X Rotary Type of Grout BENTONITE <br /> Disposal Other Other Information SLAB-BY OWNER <br /> Geophysical o Surface Seal Installed By: DRILLER <br /> IF V <br /> PUMP INSTALLATION: Contractor' <br /> Type._o"f-Pump" RIP. <br /> . <br /> PUMP REPLACEMENT: 8/ State Work Done A <br /> PUMP .REPAIR: /ill/ State Work Done., <br /> DESTRUCTION OF WELL: Well Diameter %f Approximate Depth <br /> Describe Material andk'Procedure i <br /> I hereby agree to comply,I?with all laws and regulations-of the San Joaquin Local Health District <br /> and the State of Cal-if-orniarpertaining toor regulating"well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well -I w ll�fuznish the San Joaquin Local Health District .a, <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. v Tie above i <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING ANDA FLPLIegSPECT19N. <br /> SIGNED TITLE <br /> I� {D PLOT PLAN ON RSE SIDE) <br /> FOR DEPARTMEN SE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE- 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION 'L PHASE III/-FINAL INSPECTION <br /> INSPECTION BY DATE �'-- INSPECTION BY DATE <br /> 6 2M <br /> E H 1426 Rev. - i-74'11 , <br />