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SAN JOAQUIN LOCAL`HEALTH DISTRICT <br /> FOR OFFICE USE: ii 1601 E. Hazelton Ave: ',;Stockton, Calif. <br /> Telephone: r ,(209) `466-678l <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> . �. . , f :,•t A a-....-i.dos.`h.-";t k9f2 <br /> THIS PERMIT EXPIRES1 'YEAR �FROM DATE ISSUED Date Issued ` O`7 X,. <br /> (:Complete -In.-Triplicate) <br /> Application*is hereby ;,made to the San JoaquinrLocgl. Realth District for a permit to construct <br /> and/or ins' the wol' herein described.,, .This application is made in compliance with San Joaquin <br /> Counter Ordinance No. 1862 and the Rules: and;Regulations,:of,the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 200 W. Century=-B I-vd ,a d. 4., ... ...-; CENSUS TRACT <br /> Owner's Name City of Lodi Phone 368-0641 <br /> i Address, o -Public"V1orks Dept.. 221 !WestzPririe75t --"- City Lodi <br /> Contractor's Name .Ben, Barrow Drilling.. Co... License. # 296926. Phone 662-2829 <br /> TYPE OF WORK (Check): NEW WELL /X DEEPEN.-/-7- RECONDITION /-7 DESTRUCTION /7 <br /> j PUMP INSTALLATION / / PUMP REPAIR /-7PUMP REPLACEMENT <br /> Other / / T — <br /> DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES PIT PRIVY <br /> r §EWAGE 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 34" <br /> j Domestic/private Drilled k Dia. of Well Casing 20" ID <br /> �XX Domestic/public I Driven• Gauge of Casing 4" <br /> Irrigation �' X Gravel Pack.,, Depth of Grout Seal 120 ' <br /> t Cathodic Protection X Rotary Type of Grout Cement <br /> Disposal 1� Other_ Other Information <br /> Geophysical 1 Surface Seal Installed B n C <br /> PUMP INSTALLATION: Contractor artnw } <br /> Type of Pump nqi ne*Ori vpn TiiCbi„np Tpct PUMP , H.P. 200 <br /> PUMP REPLACEMENT: j / State Work Done, <br /> t <br /> . PUMP.:REPAIR: /=7- -State-Work-Done*` .._ <br /> .. <br /> ES-TRUCTION 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 myl�work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the 11/id motif hem before putting. the. well in.use.. The above <br /> information i t e to��t -best''of my - "ledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROU NG AND FIN N ON. <br /> SIGNED Ni TITLE Vice President <br /> 'v (DRAW PLOT 'PLAN ON REVERSE SIDE <br /> . .`FOR.-DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED-BY DATE <br /> ADDITIONAL COMMENTS: <br /> PR&SE II GROUT INSPECTi N PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> � ^E H 1126 <br /> Rev. 1-7Z <br /> �. M 1-7 4 6P . <br />